Name * First Name Last Name Date of Birth * MM DD YYYY Preferred Pronouns Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Occupation * Emergency Contact Details * Your relationship to Contact * GP Name, address and contact * What are you working with in your life that you'd like to explore or support? What are your goals for our sessions together? How would you like to feel? * What are the major stressors in your life? * What do you do for a living? Is it fulfilling * Are you in a significant relationship? Is it fulfilling? * Do you have children? What are their names and ages? How is your relationship with them? * What is your support network like? (e.g., family, friends, community, health care providers, groups) * Are you taking any medication (prescribed or bought over the counter, including herbal and other supplements)? * Please list any major illnesses, surgeries, injuries, accidents and when they happened: * Do you currently have any other physical or mental health issues? If so, please give details: * Are there any areas of sensitivity (physical, psychological, allergies, preferences) that you think your trainee yoga therapist should know about to better support you? * Are there areas of your body that have restricted movement or otherwise aches/pains/limited flexibility? * What is your experience of therapy/counselling/yoga/meditation/ mindfulness/other body-mind practices? * Have you worked with any complementary health practitioners? (such as massage, acupuncture, nutritionist, reiki, shiatsu etc.) * Any other information you feel it would be helpful for your trainee yoga therapist to be aware of to better support you: * Indicate any of the following that you feel reflects your personality: * Practical Creative No nonsense Open-minded Open-hearted Spiritual Other What are your hopes, desires and passions in life? What gives you the most pleasure and joy? * Please tick any of the following that you either currently suffer from, or have experienced in the past: * Arthritis Back Shoulder or neck pain Joint or muscle damage Hypermobility Osteoporosis or Osteopenia High blood pressure Eczema Psoriasis Rosacea or Other skin issues Low blood pressure Varicose veins Asthma Allergy hay fever Other breathing difficulties Stomach duodenal ulcers Indigestion bowel disorder IBS Constipation Diarrhoea Other digestive disorders Genito-urinary issues Premenstrual tension PMDD Fibroids PCOS Menopausal symptoms Fertility issues Pregnancy childbirth difficulties Menstrual difficulties Endometriosis Heart problems Other circulatory disorders Sinusitis Chronic bronchitis Emphysema Diabetes Cancer Migraines and headaches Head injury Epilepsy Seizures ME Fibromyalgia Excessive fatigue Neurodiversity ADHD ASD Dyslexia Dyspraxia Sleep disorder Insomnia Stress Depression or Anxiety Addiction Alcohol Drugs Sex Eating disorder Bipolar disorder Schizophrenia Other psychosis PTSD Trauma Thoughts of suicide OTHER / Please give further details Do you smoke? * Do you drink alcohol? If yes, how many units per week on average? (1 medium glass of wine = 2 units / 1 pint of lager = 2 units / 1 measure of spirits = 1 unit) * Do you engage in any physical exercise? If so, what type and how often? * Do you have to travel for your job? * How do you travel to and from work? * When do you feel most energetic? * How many meals do you eat per day? * Do you drink coffee and tea? If yes, how man cups per day? * What is your sugar intake like? * How would you describe your diet? Vegan / Vegetarian / Pescatarian / includes meat / high protein or meat / Other * How would you describe your sleep patterns? * Thank you. Your form has been received and now being reviewed. New Client CONSENT FORM
