Intake Name * First Name Last Name Email * Phone * Country (###) ### #### Time Zone & Preferred Contact Method * Date of Birth * MM DD YYYY Gender * Female Male Other I am contacting SMMS: * For myself On behalf of someone else As a representative for an organization or institution What is your primary reason for seeking a yoga therapy consultation? (Select all that apply) * Spiritual growth & meditation practice Physical healing & rehabilitation Emotional or mental well-being support Stress reduction & relaxation Other (please specify): What specific challenges or concerns would you like to address? (Briefly describe) * Have you practiced yoga or meditation before? * Yes, regularly Yes, occasionally No, I am a beginner Do you have any diagnosed medical conditions? (e.g., chronic pain, heart disease, diabetes, autoimmune disorders, cancer) * Yes No Have you had any surgeries or injuries in the past 5 years? * Yes No Do you experience any of the following? (Check all that apply) * Chronic pain or stiffness Limited mobility or flexibility Joint issues (arthritis, osteoporosis, etc.) Digestive issues Respiratory concerns (asthma, allergies, etc.) Headaches or migraines Sleep disturbances Anxiety or depression High blood pressure Other Are you currently under medical supervision or taking any prescribed medications? * Yes No How would you describe your daily activity level? * Sedentary (little or no exercise) Light activity (walking, stretching) Moderate activity (yoga, fitness routine) High activity (athlete, physically demanding work) Do you follow any particular dietary patterns? * Vegetarian Vegan Ayurvedic diet No specific diet Other How many hours of sleep do you typically get per night? * 1-4 3-5 4-6 5-7 6-8 More than 8 Do you experience high levels of stress in your daily life? * Rarely Sometimes Often Constantly Are you interested in deepening your meditation or spiritual practice? * Yes No Unsure Do you follow any spiritual or philosophical traditions? * Yes No What is your preferred meditation style, if any? Vipassana Mindfulness Mantra meditation Guided meditation Other Do you have any emotional or mental health concerns you would like to address through yoga therapy? * Yes No Preferred consultation format: * Video Call (Zoom, Google Meet, etc.) Phone Call Email-Based Guidance Only Is there anything else you would like us to know before your consultation? * Yes No Thank you! Contact Us If you’re interested in collaborating, please provide your information, and we will contact you soon. We look forward to connecting with you. Name * First Name Last Name Email * Message * Thank you!
