Contact 1 — Mind, Body and Soul Counseling

Intake Form

Thank you for your interest in our Trauma Healing Group. We would like to find out a little more about you and what you are experiencing so I can better tailor classes to suit your needs. All information will be kept strictly confidential.

Thank you for sharing this information!

Name

First Name

Last Name

Phone

(###)

###

####

Preferred Contact Method

Phone

Do you have any areas in your body where you are currently experiencing physical or chronic pain? If so, please provide a brief description below

Is there anything that concerns you about joining a group yoga class?

Is there anything that you feel might be a trigger for you in a yoga class (i.e. certain postures/movements, conscious breath practice, smells/sounds etc)?

What are you hoping to get out of these classes?

Have you practiced yoga before?

Yes

... And lastly, how did you hear about these classes?