YogaFresh client intake form |

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Please read each statement and check each box to signify your understanding: *

I understand that somatic yoga therapy is provided for pain relief, stress reduction, relief from muscular tension, and improvement of circulation and energy flow.
For in-person visits, I give the provider my permission to provide hands-on assistance as needed to evaluate my situation and guide the recommended somatic yoga therapy movements.
I understand that the services offered are not a substitute for medical care. I understand that the provider is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
I affirm that I will notify the provider of all known medical conditions and injuries.
By signing this release, I hereby waive and release the provider from any and all liability, past, present, and future relating to the somatic yoga therapy sessions.

Type your full name to confirm you understand the statements above:

On an average day, what are your activities?

What's not feeling right to you (aka "what are your complaints")?

What's your history of major illnesses, injuries, surgeries? Also provide timeframe of when they occurred if you can.

If you're having pain, what increases and/or lessens it?

What are your short and/or long terms goals for your health & wellness?

What haven't I asked that you'd like me to know?

Do you have questions for me? I'll either answer them via email or at your first appointment.