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Yoga Therapy with Angie Samadhi
Street Address
Nederland, CO
Phone Number
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Yoga Therapy with Angie Samadhi
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New Client Intake
Name
*
First Name
Last Name
Birth Date
*
MM
DD
YYYY
Phone
*
(###)
###
####
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Height
Weight
How did you hear about yoga therapy and about my work in particular?:
Experience in yoga and/or meditation:
*
Current exercise program:
*
Briefly list any other bodywork modalities you have recently received (i.e., massage, reiki, acupuncture):
Briefly outline your personal support system (i.e., family, friends, health care providers, groups):
*
Please select each care provider from the following list which you have received care from within the past two years:
Medical Physician
Allopathic Specialist
Psychotherapist
Psychiatrist
Osteopath
Chiropractor
Physical Therapist
Homeopathic / Naturopathic Doctor
Religious/Spiritual Counselor
Yoga Therapist
Other
Please include relevant details of the treatments or sessions you received:
Please list below any prescription or non-prescription medication you are currently taking:
Please list any history of surgeries, major illness, chronic conditions, accidents, injuries, or anything that might be relevant to doing yoga therapy which were not previously listed:
Please check any condition which applies to you:
Addiction
Amputation
Anxiety
Arthritis
Asthma
Autoimmune Disease
Bi-Polar Disorder
Bulging/Herniated Disc
Cancer
Chronic Fatigue
Degenerative Disc Disease
Depression
Eating Disorder
Emphysema
Fibromyalgia
Fused Vertebrae
Grief
Heart Condition
Hernia
High Blood Pressure
History of Abuse
HIV/AIDS
Hepatitis
Injury / Surgery -Related Scar tissue
Irregular Menses
Low Blood Pressure
Menopause (Current, Pre or Post)
Multiple Sclerosis
Osteoporosis
Chronic Pulmonary Obstructive Disorder
Sleep Apnea
Insomnia
Parkinson’s Disease
Postpartum
Pregnancy
Pregnancy Loss
Trauma - Brain
Trauma - Physical
Trauma - Sexual
Work-Related Injury
Other
Please describe area of body effected, timeline of experience and/or stage of experience or treatment:
Please describe any other conditions or life challenges not listed but which may impact your daily living:
What do you hope to receive from a yoga therapy session?:
*
Is there anything else you’d like me to know before we begin our work?:
Consent & Release:
*
I am aware that Angie is not licensed under the laws of this State to practice any form of medicine.
I understand that Angie is a certified yoga therapist and will neither diagnose, nor prescribe for any condition or problem from which I may appear to be suffering, but will refer me to an appropriate practitioner, if necessary.
I understand the said individual practices of Angie Samadhi, InterBody Wellness and Yoga Therapy are a holistic healing art combining the ancient science of yoga with elements of contemporary body/mind psychology.
I understand a session with Angie includes touch, assisted yoga postures, and client-centered dialogue and that I have an option to request non-touch work, if desired.
I understand a session with Angie is not a substitute for medical treatment and I understand that no guarantee or promises of cures have or will be made to me and that any benefits which I experience come from within my own awareness and self-knowledge.
By typing my name below, I agree to the above Consent and Release:
*
Today's Date
*
MM
DD
YYYY
Thank you!