check

Trauma Sensitive Yoga Application

Please complete this application form to attend a Trauma Sensitive Yoga series.

After viewing your application we will be in contact within 7 days to secure your place on the requested session, at which time you will be required to make your deposit to reserve your place within 7 days. 

Click the button below to start.

Start

Question 1 of 17

Full Name 

Question 2 of 17

Email Address 

Question 3 of 17

Phone Number

Question 4 of 17

Date of birth

Question 5 of 17

Emergency contact details 

Optional Information: this would be useful information if you feel happy to provide it.

New Question

Question 7 of 17

Do you suffer from:

(Select all that apply)
A

Anxiety

B

Arthritis

C

Asthma

D

Back Problems

E

Bronchitis

F

Cancer

G

Circulation Problems

H

Depression

I

Emphysema

J

Headaches

K

Heart Attack

L

Blood Pressure (high or low)

M

Insomnia

N

Neck Problems

O

Pregnancy

P

PTSD

Q

Recent Surgery

Question 8 of 17

Please provide any additional information you would like above any of the above selected items.

Question 9 of 17

Sometime in life things happen in our lives that can have a indirect impact on our health. These can be valuable to share so I can fully support you. This is your choice to share this on this form or by reaching out to me on 0426279791. 

(Select all that apply)
A

Have you ever experienced a recent loss or trauma?

B

Do you experience nightmares or flashbacks of past events?

C

Do you feel that you are able to take good care of yourself?

D

Do you ever experience situations where you realise you weren’t fully present?

Question 10 of 17

Are you currently seeing a counsellor, psychologist, mental health ot, social worker, psychiatrist?

A

Counsellor

B

Psychologist

C

Mental Health OT

D

Social Worker

E

Psychiatrist

F

None

G

Multiple

Question 11 of 17

Are you taking any medications? If yes couple you please outline these?

Question 12 of 17

Are you taking any herbs, vitamins, homeopathics? If yes can you please outline ?

SERIES OUTCOMES

If you have no idea right now that’s totally fine. If you do it is helpful if you can share why you have decided you would like to do this series?

Question 14 of 17

Why did you want to do this series?

Question 15 of 17

What would you like to achieve /gain by attending this series ?

Question 16 of 17

Is there any particular additional support you need from me to achieve these outcomes? 

Question 17 of 17

ACKNOWLEDGMENT: I am willing to accept my won self responsibility and self care in these sessions and will take appropriate action to rectify any problems I experience. This may. Mean stopping the actual practice and/or speaking to the facilitator. I will inform the facilitator of any changes to the information covered in this application before and/or during the series, should any changes occur.

A

I agree

B

Please call me before I agree

Confirm and Submit