Yoga Therapy Intake Form

Name(Required)

Date of Birth(Required)

Email(Required)

Mobile(Required)

Occupation / Current work situation(Required)

Name of GP

Contact Number of GP

Support worker/Psychiatrist/Psychotherapist Contact Details (if relevant)

Emergency Contact Name(Required)

Emergency Contact Relationship to you(Required)

Emergency Contact Mobile(Required)

1. Are you currently taking any medication (prescribed by your doctor or bought over the counter, including any herbal or other supplements)?(Required)

Please note, I will never suggest that you stop or change any prescriptions. I am only asking this to consider the symptoms they are treating and the potential side effects which may be relevant for the way we work.

Yes (If yes, please give details below)

No

Details

2. Have you had any major physical illnesses or accidents in the past you think are relevant for me to know about?(Required)

Yes (If yes, please give details below)

No

Details

3. Do you have a psychiatrist?(Required)

Yes (If yes, please give details below)

No

Details

4. Please give details of any mental health diagnosis, treatment or symptoms you think are relevant for me to know.(Required)

You may like to include how this affects you on a day-to-day basis. How long you have been experiencing difficulties. If you have a diagnosis, and if you have had or are currently having any treatment.

5. Have you ever been diagnosed with, or do you consider yourself to be neurodiverse?(Required)

Yes (If yes, please give details below)

No

Details

11. How does stress tend to affect you physically, mentally and behaviourally?(Required)

You may like to give details Include physical effects such as chronic pain, migraines, brain fog, muscle tension, stomach complaints etc and emotional effects such as low mood, irritability, anxiety, rage, lethargy, depression, suicidal thoughts, self-harming behaviours, eating patterns etc.

12. What are the main sources of stress in your life currently? (Required)

13. How often has poor sleep troubled you in the last month?(Required)

14. How are your energy levels currently? (Please give details)(Required)

15. What resources do you currently have access to help you cope in difficult times?

You may like to give details include things such as self-reliance, determination, self-compassion, religious beliefs, or spending time with friends, being outdoors in nature, exercise, alternative therapies, art, music, hobbies etc.

Laura Wilson Trauma-Informed Yoga and Somatic Therapy