Hawaii Yoga Therapy
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Hawaii Yoga Therapy Intake Form
Before your session we'd like to get to know you a bit . . .
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Name
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Email
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Phone Number
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What is your age?
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Less than 13
13-18
19-25
26-35
36-50
Over 50
Prefer not to say
What are your current reasons for seeing a Yoga Therapist?
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What Yoga Therapy tools are you most interested in?
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Structural Rehabilitation
Somatic Inquiry
Ayurveda
Meditation
Mudra & Mantra
Tantra
Jyotish
Dance
If Other please specify:
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List your current & previous health conditions? Please include any medical or mental diagnoses, surgeries, accidents, injuries, etc.
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What are your favorite physical movements? Least favorite?
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How often do you spend time in nature?
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
How do you typically handle emotional and stressful situations?
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If you could change one habit, what would it be?
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What aspects of your life give you the most joy and pleasure?
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