Client Initial Consultation Form

Client Initial Consultation Form

For exclusive use of She-Wolf Wellness
Date

Month Day Year
Date
Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Age
Gender

Female Male
Do you own a yoga mat?

Yes No
Emergency Contact 1

First Name Last Name
Area Code Phone Number
Emergency Contact 2

First Name Last Name
Area Code Phone Number
Reason for interest in personal yoga / wellness sessions

Fitness Increased Mobility Flexibility Strength Stress Relief Health Issues Increase Focus / Concentration Something New
Health Record

Back Pain Neck Pain Arthritus Anxiety Depression Posture Stress Disability Chronic Low Back Pain Asthma Heart Disease Lung Disease Heatstroke Anemic Pregnant Postnatal High Blood Pressure Insomnia Diabetes (or at risk) HIV Low Immune System Menapausal Symptoms Multiple Scerosis Post Traumatic Stress Disorder Smoking Cessation Glaucoma Sciatica Dizziness / Light - Headedness
Do you currently have any other physical injuries or health conditions you are working with?
Any other past injuries, surgeries or health conditions?
Are you currently taking any medications?

Yes No
If yes, please list which and what they are taken for.
Are there any places in your body that you experience pain or feel you are holding stress? If so, where?
Yoga, meditation and other methods we will incorporate are known to have many positive effects on those who experience depression, anxiety and stress. Is there anything you would like to share or focus on alleviating / balancing concerning emotional wellbeing?
What (if any) are your concerns about beginning a wellness practice?
What are you most looking forward to accomplishing with our sessions?
What other activities do you participate in, physical or otherwise?
What are you passionate about?
Is there anything further you would like to share?
As far as I am aware, I have disclosed to She-Wolf Wellness all information regarding my health relevant to the services provided.

I take full responsiility for my body and my participation in the agreed upon activities.

I fully understand that the recommendations, ideas or techniques expressed and described for these sessions cannot be regarded as substitute for the advice of a qualified medical practitioner.

Any uses to which the recommendations, ideas and techniques are put are at my sole discretion and risk.
Electronic Signature ( Required ) *

Clear
Are you ready to meet the best version of you?
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