Client Intake Form

Name *

First

Last

Cell Phone

Email *

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact

How did you hear of us? *

What are your goals with Yoga Therapy? *

Have you had any injuries or surgeries in the last year? *

Medicines? (please list reasons for each and dosages if possible) *

Faith? (optional)

What is your regular exercise program? *

Diagnosed Chronic Issues? *

What are symptoms you are experiencing? *

What typically makes it feel better? *

On a scale of 1-10, 10 being worst, what would you rate your symptom intensity? *

Please list other health care providers with whom you are currently working: *

How long have you been practicing yoga? *

What is your regular daily routine from awakening to going to bed at night? *

Do you sleep well? *

Yes
No

Do you fall asleep easily *

Yes
No

Do you awaken during the night? *

Yes
No

Can you easily get back to sleep? *

Yes
No

Average number of hours?

Are you a primary caregiver to children, aged parents or anyone else? *

Yes
No

If a primary caregiver, how long?

On a scale of 1-10, 10 being the best, please rate the following:

Physical Fitness *

Physical Health *

Nutrition *

Water Intake *

Coping Skills *

Self-esteem *

Marriage or Partner *

Connection to family *

Profession *

Organizational skills *

Social Skills *

Playtime *

Spirituality *

Comment or Message *

Please sign and Date

I agree to participate in Yoga Therapy or private yoga with Ena Rodriguez. I understand that our work is confidential. This is a physical practice; despite the education, experience and discernment of the teacher, I accept the inherent risk of movement therapy.

Cancellation Policy:

For a first cancellation, there is no charge. Please call within 24 hours to cancel to avoid a $20 fee. No shows are charged for that session.

Date *

Signature *

Clear Signature

19 Old Town Square - Suite 238
Fort Collins, Co 80524

Client Intake Form

Please sign and Date

Cancellation Policy:

Thank you so much for your trust!

19 Old Town Square - Suite 238 Fort Collins, Co 80524

Client Intake Form

Please sign and Date

Cancellation Policy:

Thank you so much for your trust!

19 Old Town Square - Suite 238
Fort Collins, Co 80524