Yoga for Grief Relief Intake Form
Name Today’s date:
Referred by Nature of relationship?
Contact Information:
1.
Mailing address 2. Telephone / Fax (home) 3. Cell phone / (other) 4. E-mail address
5. Emergency contactTelephone relationshipBasic Personal Information:
6. Place and date of birthEthnic origin7. Occupation 8. Hobbies or recreational activities 9. What is your religious or spiritual affiliation, if any?
Family Profile:
10. Are you single, partnered or married?
Sexual orientation? (optional)
11. Are you a child of divorce?
Have you divorced?
Had traumatic separation?
12. Who do you live with now?
13. Do you have children?
How many?
Names/ages?
14. Are your parents alive?
If deceased, when?
15. Do you have siblings?
Where do they live/ages?
16. Do you wear dentures/prosthesis?
17. Do you regularly use any substances?
alcohol?
tobacco?
18. Surgical history?
19. Please list any chronic condition/illness you suffer from:
20. List all current medications 21. Please list any chronic conditions/illnesses in your family?
22. Please indicate which of the following currently apply to you:
over sleeping
over eating
hormonal irregularities
upper back pain
insomnia
loss of appetite
menstrual irregularities
mid back pain
shortness of breath
palpitations
neck pain
lower back pain
constant sighing
arrhythmia
skin conditions
chest pain
23. Have you suffered a recent injury?
old injuries?
If so, what/when?
24. Any chronic or acute, physical or emotional pain not listed below?
25. Please indicate which of the following currently apply:
depression
anger
irritability
confusion
mood swings
anxiety
paranoia
fear
apathy
compulsiveness
panic attacks
exhaustion
Relief
crying
loss of memory
guilt
numbness
resentment
emptiness
loneliness
26. How would you assess your stress levels?
On a scale of 1-10?
Previous Therapeutic Experiences:
27. Have you experienced any complementary / integrative (alternative) therapies?
acupuncture
feldenkrais
pilates
Alexander Technique
aromatherapy
flower essences
breathwork
hypnotherapy
imagery
28. Are you now engaged in other therapies? Which?
Current Activities:
29. Do you exercise regularly?
Which form of exercise/how often?
30. Do you practice Yoga? Which style/how often?
reiki
role playing
sound/vibrational therapy
Loss related Questions:
31. Have you suffered a recent loss?
What loss/when?
32. Why are you seeking treatment?
33. What has prompted your visit?
34. I have stated all my known medical, emotional and physical circumstances and will keep the Yoga for Grief Relief
practitioner updated about changes in my condition.
35. I understand that Yoga for Grief Relief (a combination of verbal counseling and somatic yoga based movements) is for
the purpose of alleviating grief related ailments and promoting a sense of well-being. I understand that the Yoga Therapist does
not diagnosis illness, disease or any other physical or mental disorder; or prescribe medical treatments or remedies. Yoga
Therapy is not a substitute for licensed medical care, consultations or examinations.
36. Full payment is due at time of session unless prior arrangements are negotiated.
37. I assume responsibility for full payment of any scheduled session that I cancel without at least 24 hours prior notice.
38. Termination of current treatment must be done in a formal in-person session (or Skype or phone session if that is the
usual medium). Termination through any other medium leaves the therapeutic process unfinished. Appropriate closure is
required for future re-initiation of treatment, if desired.
39. I have read and agree to the above statements and conditions.
Signature:_______________________________________________ Date:_____________________________
Yoga for Grief Relief
P.O. Box 64, Fairfax, CA 94978-0064
415.258.2830
www.yogaforgriefrelief.com