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Old form for yoga Theraphy

Please complete this intake form and we will be in touch to discuss organising your initial consult.

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PERSONAL INFORMATION

Please complete as much as possible 

Question 2 of 14

Your Full Name & Contact Number

Question 3 of 14

Your Email Address 

Question 4 of 14

Your Home Address 

Question 5 of 14

Your Date of Birth 

Optional Information

Some additional information can be helpful so that we are able to support you best during the series. Please feel free to complete as much or as little as you would like from the following section. 

Question 7 of 14

Yoga/Meditation/Mindfulness experience (including style of practice, outline daily/weekly practice schedule and years practicing)

Question 8 of 14

What would you like to gain from attending a Trauma Sensitive Yoga series?

Question 9 of 14

Do you (or have you ever suffered from) 

(Select all that apply)
A

Stress related tension

B

Digestive issues

C

Asthma/lung conditions

D

Chronic pain

E

Circulatory/Heart condition

F

Fatigue

G

Headaches/migraines

H

High blood pressure

I

Low blood pressure

J

Sleeping difficulties

K

Menopause problems

L

Depression

M

Weight loss

N

Weight gain

O

Back pain

P

Neck pain

Q

Intervertebral disc problems

R

Knee problems

S

Hip problems

T

Arthritis

U

PMT

V

PTSD

W

Anxiety

Question 10 of 14

If you ticked any on the last question please outline more information here

Question 11 of 14

Outline any medical conditions (including allergies)

Question 12 of 14

Emergency contact including name, relationship and contact details

Question 13 of 14

Any additional information you feel we need to know.

Question 14 of 14

When registering for the next 6 week series you acknowledge that a more comprehensive intake form will be completed 

A

I am aware

Confirm and Submit