Yoga for Grief Relief Intake Form

Name - Today’s date:
Referred by - Nature of relationship?
Contact Information:
  1. Mailing address -

  1. Telephone / Fax (home) -

  1. Cell phone / (other) -

  1. E-mail address

  1. Emergency contact- Telephone - relationship-

Basic Personal Information:
  1. Place and date of birth- Ethnic origin-

  1. Occupation -

  1. Hobbies or recreational activities -

  1. What is your religious or spiritual affiliation, if any?

Family Profile:
  1. Are you single, partnered or married? Sexual orientation? (optional)

  1. Are you a child of divorce? Have you divorced? Had traumatic separation?

  1. Who do you live with now?

  1. Do you have children? How many? Names/ages?

  1. Are your parents alive? If deceased, when?

  1. Do you have siblings? Where do they live/ages?

  1. Do you wear dentures/prosthesis?

  1. Do you regularly use any substances? alcohol? tobacco?

  1. Surgical history?

  1. Please list any chronic condition/illness you suffer from:

  1. List all current medications -

  1. Please list any chronic conditions/illnesses in your family?

  1. 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
  1. Have you suffered a recent injury? old injuries? If so, what/when?

  1. 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 / reiki
Alexander Technique / aromatherapy / flower essences / role playing
breathwork / hypnotherapy / imagery / sound/vibrational therapy
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?
Loss related Questions:
31. Have you suffered a recent loss? What loss/when?
  1. Why are you seeking treatment?

  1. 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