Intake Form – treetop-creative – Treetop-Creative, Inc.

Name

First

Last

Cell Phone

Email

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact

How did you hear of us?

What are your goals with Yoga Therapy?

Have you had any injuries or surgeries in the last year?

Medicines? (please list reasons for each and dosages if possible)

Faith? (optional)

What is your regular exercise program?

Diagnosed Chronic Issues?

What are symptoms you are experiencing?

What typically makes it feel better?

On a scale of 1-10, 10 being worst, what would you rate your symptom intensity?

Please list other health care providers with whom you are currently working:

How long have you been practicing yoga?

What is your regular daily routine from awakening to going to bed at night?

Do you sleep well?

Yes
No

Do you fall asleep easily

Yes
No

Do you awaken during the night?

Yes
No

Can you easily get back to sleep?

Yes
No

Average number of hours?

Are you a primary caregiver to children, aged parents or anyone else?

Yes
No

If a primary caregiver, how long?

On a scale of 1-10, 10 being the best, please rate the following:

Physical Fitness

Physical Health

Nutrition

Water Intake

Coping Skills

Self-esteem

Marriage or Partner

Connection to family

Profession

Organizational skills

Social Skills

Playtime

Spirituality

Comment or Message

Please sign and Date

I agree to participate in Yoga Therapy or private yoga with Ena Rodriguez. I understand that our work is confidential. This is a physical practice; despite the education, experience and discernment of the teacher, I accept the inherent risk of movement therapy.

Cancellation Policy:

For a first cancellation, there is no charge. Please call within 24 hours to cancel to avoid a $20 fee. No shows are charged for that session.

Date

Signature

Clear Signature

Client Intake Form

Please sign and Date

Cancellation Policy:

Thank you so much for your trust!

Cinematic Vertical Productions

Executive Producers