New Teen Client CONSENT FORM 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 your goals for this mind/body work? Is there something you're working with in your life that you’d like to explore? * Are you taking any medication (prescribed or bought over the counter, including herbal and other supplements)? * Please list any major illnessesPlease list any major illnesses, surgeries, injuries, accidents, trauma, major life events or anything else your trainee yoga therapist should be aware of. * 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 yoga/meditation/mindfulness/other body-mind practices? * Have you worked with any complementary health practitioners? (such as masseur(euse), shiatsu practitioner, acupuncturist, nutritionist, reiki provider, etc). Please provide details (type of practice, purpose, results etc.): * Briefly outline any of your personal support system that you may or may not have (eg, family, friends, community, health care providers, groups): * Any other information you feel it would be helpful for your trainee yoga therapist to be aware of to better support you: * 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? * Have you ever practiced yoga before? Please provide details of how long, what styles, and what your experience of it has been.a * Do you have experience of mindfulness or any other style of meditation or mind-body practice? * What aspect of yoga therapy is most interesting to you? * Do you have any concerns about yoga therapy? If so, please describe * Indicate any of the following that you feel reflects your personality: Practical Creative No nonsense Open-minded Open-hearted Spiritual Other OTHER / Please give further details Hobbies/interests/activities that bring you joy: * Thank you. Your form has been received and now being reviewed.
