Intake Form

Hawaii Yoga Therapy

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Hawaii Yoga Therapy Intake Form

Name *

Email *

Phone Number *

What is your age? *

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? *

What Yoga Therapy tools are you most interested in? *

Structural Rehabilitation Somatic Inquiry Ayurveda Meditation Mudra & Mantra Tantra Jyotish Dance

If Other please specify: *

List your current & previous health conditions? Please include any medical or mental diagnoses, surgeries, accidents, injuries, etc. *

What are your favorite physical movements? Least favorite? *

How often do you spend time in nature? *

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? *

If you could change one habit, what would it be? *

What aspects of your life give you the most joy and pleasure? *

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