Name
*
First Name
Last Name
Which yoga therapy program(s) are you interested in?
*
Select all that apply
Have you ever participated in a Mindful Grieving program in the past?
*
Yes
No
Email Address
*
Phone
*
Country
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What is the best way to contact you?
*
Email
Phone
Text Message
Birth Date
*
MM
DD
YYYY
Pronouns
Occupation
*
Marital Status
*
Single
Married
Significant Other
Widowed
Separated
Divorced
Other
Do you have children?
*
Yes
No
Emergency Contact
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First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
What kind of loss have you experienced?
*
Select all that apply
When did your loss(es) occur?
*
How is your loss affecting you now?
*
Have you had more than one loss in the last 5 years?
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Yes
No
Are you currently in counseling?
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Yes
No
What is your current support system?
*
Have you experienced any events that you would consider traumatic, whether related to this loss or not?
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Yes
No
If so, please explain.
Have you ever attempted or considered suicide?
*
Yes
No
If so, was there any follow-up treatment? If so, what?
Are you currently taking any medications for depression, anxiety, or other mental health issues?
*
Yes
No
Have you ever been hospitalized for psychiatric reasons?
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Yes
No
If so, what?
Do you currently experience any fighting in your household?
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Yes
No
If so, please explain.
Do you currently practice yoga?
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Yes
No
Not currently, but I have previous yoga experience.
Are you currently pregnant?
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Yes
No
Do you have any illness or injury that might impact your yoga practice?
*
Yes
No
If so, please explain.
Why are you interested in participating in a Mindful Grieving Yoga Therapy Program?
*
Is there anything else that you would like me to know?
How did you hear about Katy's Mindful Grieving Yoga Therapy Programs?
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Referral from a Friend/Family Member
Internet Search
Center for Somatic Grieving Website
Social Media
Other
Would you like to be added to my email list to receive occasional updates on my schedule and offerings? (No spam or daily emails, I promise!)
By submitting this form, you acknowledge receipt and agreement with the Liability Release Form . This constitutes your electronic signature.
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