Mindfulness & Embodied Presence | Yoga Therapy & iRest with Ena Rodriguez O’Rourke

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Intake FormBrandesigns2026-04-21T18:02:59+00:00

Client Intake Form

Thank you for completing your intake form. If you need a printable copy for your records or prefer to submit it by email, you can download the form.

Printable Client Intake Form

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- Step 1 of 7

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? *

Do you fall asleep easily *

Do you awaken during the night? *

Can you easily get back to sleep? *

Average number of hours?

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

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

Thank you so much for your trust!

Connect with Ena

If you’re seeking information about yoga therapy, iRest® meditation, workshops, or embodied presence sessions please complete this form. Providing these details helps Ena prepare thoughtful next steps and ensures your inquiry is routed correctly for scheduling and follow‑up.

Mindfulness Inquiry

Client Intake Form

Please sign and Date

Cancellation Policy:

Thank you so much for your trust!

Connect with Ena

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Executive Producers