Client Information and Enrollment Agreement

Before your session begins, please take a moment to complete the two forms below:

  1. Client Information

  2. Enrollment Agreement

Client Information Form

Section One
Basic Information
Name *
Name
Phone *
Phone
Please provide your best contact number
Address
Address
Section Two
Home and Family.
Section Three
Tell us more about your profession.
Section Four
Medical and Health Information.
Please answer if you have worked with a counselor in the past.
Present Counselor
Present Counselor
Present Psychiatrist
Present Psychiatrist
Present Primary Physician
Present Primary Physician
Let us know of any past Medical History you feel may impact your ability to complete the eight week series.
Please let us know if you have any history of depression, anxiety, bi-polar, ADHD, Schizophrenia, Substance Abuse, or areas which may impact your participation in the 8-week series.
Please list any medications you are currently taking and the reason for taking them.
Section Five
Preventative and Holistic Care.
Tell us what you currently do for exercise.
Describe you level of experience with Yoga and Meditation.
Please let us know of any injury or limitations you may have physically to keep you from engaging in the practice fully.
What do you enjoy most with your time.
Social Support
Please select all that apply for you below.

Enrollment Agreement

Please take a moment to review the Enrollment Agreement (click for downloadable pdf). Once you have read the agreement, complete the simple form below. 

Name *
Name
Date *
Date