Name
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First Name
Last Name
Age
Preferred Pronouns
Email
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Phone
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(###)
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact + Phone number
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Referred by:
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Please breifly describe what you are currently experiencing, including onset and diagnosis (if applicable):
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What is your current level of activity?
On a scale of 1-10 (1 is the lowest, 10 is the highest), how would you rate your level of stress?
Please explain physical history including any condition that have affected your health either recently or in the past:
Please list other services you are receiving that may be helpful for me to know (i.e. mental health therapy, physical therapy, acupuncture, etc.).
Describe any concerns, differences or observations you have made regarding your physical body in relation to the challenge(s) you are currently experiencing:
Describe any concerns, differences or observations you have made regarding your energy in relation to the challenge(s) you are currently experiencing:
Describe any concerns, differences or observations you have made regarding your mental/emotional state in relation to the current challenge(s). These may include thoughts, cognitive changes and/or emotions:
What are your central religious/spiritual beliefs and practices, both current and past (if any), and how have these been affected in relation to the current challenge(s)?
What do you think is getting in the way of making the changes you want in your life?
If you woke up tomorrow living your ideal life, what would it look like (i.e. physically, energetically, mentally/emotionally and/or spiritually)?
Briefly describe a typical day for you. What do you like to do in your free time?
What do you hope to gain from yoga therapy and/or the Feldenkrais method? What do you most hope to have addressed?
Is there anything else you would like me to know about you that I did not ask?
I agree to pay all fees at the beginning of our session. The fee per session is $125
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Cancellation policy: There will be no charge if appointments are cancelled 24 hours in advance. Cancellations within 24 hours of the scheduled time will be charged the full fee.
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Please initial which form of communication you prefer.
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I understand that Yoga and the Feldenkrais Method incorporate both cognitive and physical approaches, and that there is an inherent risk when participating in physical activities. I agree to let the therapist know of any physical limitations I might have, or any physical activities I do not wish to participate in. I hereby release Sarah Baumert, Sarah B. Yoga, Inc., BODY MATTER and all other sponsoring agencies from responsibility for any injuries I may sustain as a result of participation in this program.
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