Your Place For Yoga Therapy & HealingYoga Therapy • Yoga Classes • Yoga Teacher Training • HypnosisCranial Sacral Therapy • Acupuncture • The Feldenkrais Method

1608 29th Ave. North, St. Petersburg, FL 33713(727) 826-4754 • www.livingroomyoga.biz

LIVING ROOMYOGA

New Student Form/Wellness Questionnaire for Cranial Sacral Therapy

* Living Room Yoga uses your e-mail address to send out updates regarding your account status, reminder updates for classes or workshops you have been booked into, special promotions/coupons, and our weekly studio update newsletter. Your personal information will never be sold to a third party. You can unsubscribe from our electronic communications at any time.

Name:

Address:

City: State: Zip:

Cell Phone: ( ) -

Home Phone: ( ) -

E-Mail*:

Birth Date:

Gender: Male Female

Emergency Contact:

Emergency Contact Relationship:

Emergency Contact Phone: ( ) -

Name of Your Healthcare Provider:

Phone Number of Healthcare Provider: ( ) -

Medications You Are On and What Are They For:

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Living Room Yoga New Student Form/Wellness Questionnaire for Cranial Sacral Therapy

What is your experience with Cranial Sacral Therapy?

What would you like the outcome of your private appointment to be?

If your body could talk, what would it say about its state of being?

How is your diet and digestion?

Where do you have muscle pain or tension?

How would you describe your posture?

What kind of work do you do?

Is your body comfortable at work? Yes No

What kind of exercise do you do, and how often?

What do you do for stress reduction and relaxation? Feel free to share unhealthy habits as well as healthy ones.

What major surgeries have you had?

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Living Room Yoga New Student Form/Wellness Questionnaire for Cranial Sacral Therapy

What chronic conditions do you have?

List any accidents or injuries with approximate dates:

What are your main health challenges right now?

To what extent do these challenges restrict your daily life?

Is your schedule: Regular Irregular

Do you have any problems with breathing? Yes No

Do you notice changes in your breath when you become upset or agitated? Yes No

What happens?

Were you ever a smoker? Yes No

If you are still a smoker, do you want to quit? Yes No

Is your energy level: Low Medium High

Does your energy level fluctuate? Yes No

When do you have dips?

What are your sleep patterns like?

Do you wake up refreshed? Yes No

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Living Room Yoga New Student Form/Wellness Questionnaire for Cranial Sacral Therapy

Is your stress level: Low Medium High

What triggers your experience of stress?

What do you find most effective for releasing stress?

Do you find yourself getting upset or irritated often? Yes No

Do you experience anxiety? Yes No

Do you experience depression? Yes No

What emotions do you have difficulty experiencing or expressing?

Are personal relationships nurturing and supportive? Yes No

Is your career fulfilling? Yes No

What are your main life challenges at present?

What have been your most significant losses?

Do you have friends you can confide in? Yes No

Do you notice that you keep bumping up against the same problems or situations in life? What are they?

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Living Room Yoga New Student Form/Wellness Questionnaire for Cranial Sacral Therapy

What habits would you like to change?

Do you have the big picture of your life or do you feel stuck in the forest just looking at the trees?

How would you describe the spiritual dimension of your life?

What are the most important things in life?

Do you feel like you have a particular mission in this life?

If so, are you fulfilling it?

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Living Room Yoga New Student Form/Wellness Questionnaire for Cranial Sacral Therapy

Please Check The Goals Below That Are Most Important To You:Improve Digestion and EliminationImprove PostureImprove Overall HealthIncrease Body AwarenessImprove BreathingIncrease EnergyStabilize EnergyImprove SleepHandle Emotions Better

Be Able to Feel Emotions in the BodyGet Less Upset and IrritatedFeel Less AnxiousFeel Less DepressedFind Greater Fulfillment in My Work LifeImprove Self EsteemGain a Wider Vision of LifeGrow SpirituallyHave A Sense of Living Life Fully

Have a Live Experience of the Meaning of Life Have More Control Over the Direction of My Life See and Change Dysfunctional Behavior Patterns Have More Satisfying Personal Relationships Improve Diet and Develop a Healthier Lifestyle Reduce Experience of Stress/Attain Greater Peace of MindMuscle Strengthening (Which?)Flexibility (Where?)Joint Stability (Which?)Reduce Pain (Where?)Change Habits (Which?)Learn Specific Postures or Aspects of Yoga

How DiD You Hear about us - Please mark only one

Facebook Fan PageReferral by Member: _______________________Online Info FormHealthcare Provider: _______________________Driving By/SignLinkedInCrowdSavingsLiving Room Yoga Car

St. Pete/Tampa Bay TimesTampa Bay Wellness MagazineTransformations MagazineInternet SearchFlyer in Coffee Shop: _____________________EversaveLivingSocialOther: _________________________________Bay News 9

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Living Room Yoga New Student Form/Wellness Questionnaire for Cranial Sacral Therapy

Cranial Sacral Therapy Liability Waiver

I am aware that cranial sacral therapy may temporarily increase my pain or cause me to revisit pains from past injuries on my way to healing. I understand that during treatment, I may experience a myriad of sensations including heat or pulsing and that this is an indication of a therapeutic result. I certify that I have disclosed all relevant health problems to Living Room Yoga prior to beginning the program, so the therapist can adjust treatment appropriately. I agree to take responsibility for my own safety by letting the occupational therapist know if I experience pain or discomfort. I acknowledge that the occupational therapist has not and will not render medical services, including medical diagnosis of my physical condition. I specifically agree that Living Room Yoga shall not be liable for any claim, demand, cause of action of any kind whatsoever for, or on account of death, personal injury, property damage, or loss of any kind resulting from or related to my use of equipment or participation in cranial sacral therapy on the premises of Living Room Yoga. I agree to hold Living Room Yoga harmless from same.

I have read the above release and waiver of liability and fully understand its contents. I signify by signing below that I voluntarily agree to the terms and conditions stated above from this date forward in all my dealings with Living Room Yoga.

Printed Name

Signature Date

Cancellation Policy Acknowledgement

By signing below, I agree to provide notice of cancellation by Noon of the previous business day in order not to be charged for the missed session. Weekend and Monday appointments must be cancelled by 12:00 noon on the Friday before in order not to be charged for the appointment.

Printed Name

Signature Date

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