Intake Form

Welcome to Ascend Wellness

Please complete this intake form and submit it before our initial session. The intention is to consider what it is you are seeking, and how yoga therapy can support you.

Todays Date

Name

Age

Address

Phone

Occupation

Next of Kin

Contact number

What brings you to yoga therapy?

Is there an area or something in your life you would like to explore?

What are you hoping to receive?

In what ways do you currently pay attention to your mind and body to take care of yourself? Do you receive any type of body/mind/therapy work? (Yoga, Massage, Physiotherapy, Psychological Therapy?)

Do you receive any type of body/mind/therapy work? (Yoga, Massage, Physiotherapy, Psychological Therapy?):

Please list a history of any surgeries, major illnesses, conditions, injuries or anything else which I should be aware of when working with your body.

Are you taking any prescription or non-prescription medication? If yes, for what reason?

How did you find out about yoga therapy?

Is there anything else you would like me to know before we start our work together?

By checking this box and submitting this form you agree to Ascend Wellness processing and storing my data in accordance with The Data Protection Act 2018. For more information please view our GDPR Policy.