One on One Intake

Yoga with Kaya Resources

About
SRY
Ayurveda
Work with Me
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Welcome! This information will remain confidential and goes directly to me. Your application allows me to establish if

my work will truly be effective for you
working with you is within my scope of practice
which specific techniques might be most useful and effective
which package and level of commitment would best suit you

I will contact you after receiving your application.

Yoga Therapy Form - New Client

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Please leave a cell phone if possible, in the case of cancellation or schedule changes.

Main Concerns you hope to address with Yoga Therapy with Kaya - include any medical diagnoses, symptoms, and time of onset / number of years. *

Other Modalities you are currently using (or have tried in the past) *

Yoga classes Acupuncture / Chinese Medicine Ayurveda Massage Nutritional Therapy Cardio Exercise Strength Training Physical Therapy Psychotherapy / Counseling Other

What that you have tried has been especially effective or ineffective? *

Check all that apply *

High Blood Pressure (even if treated by medication) Pain that prevents me from "doing a day" without rest Pregnant Post partum Low back pain Neck / Shoulder pain Headaches Anxiety Depression Insomnia Hyperactivity Low Motivation Spinal disc problems PTSD Physical Disability or Mobility Impairment Panic Disorder or phobia {such as agoraphobia} Other mental illness or psychiatric disorder Other None of the above

Please describe any major life changes or difficulties that may be contributing to any physical or mental pain. *

Do any of these apply to you? *

I have some normal aches / pains / discomfort but live a full, active life with few complaints I have some physical or mental discomfort but I am good at "pushing through" and can live a pretty full life My physical / mental discomfort is somewhat limiting and I can't do a "full day" without taking a nap or a rest My physical / mental discomfort or diagnosis is so limiting that it is effecting my relationships/work/sense of joy and purpose

Please describe your daily sleep routines {waking and sleeping times} and quality of sleep as well as how you feel when you wake up in the morning. *

Are you interested in a home yoga practice? *

Please describe your MEAL TIMES and what you eat? Also include snacks, drinks, coffee, tea, etc. *

Group Classes *

I already attend group yoga classes in Spinal Release Yoga I attend group yoga classes in another style of yoga I am interested in group yoga classes I am not interested in group yoga classes

What limitations might prevent you from getting better? (financial, time restraints, relationships, etc) *

Expand on your interest in home yoga practice, if you want to. *

What in your life can support you in your healing process or yoga practice? (Supportive partner, family, lots of time, enough money to dedicate to myself, etc.) *

Are you interested in cultivating self-care and lifestyle practices such as dietary or sleep routines and taking herbal medicine? *

Birthdate, Location, and if available exact time (or if you do not want to share, give your age) *

How did you hear about Yoga with Kaya? *

Expand on your interest in self care, if you want to *

Submit

Kaya is the founder of SRY™ which is based in the full spectrum of the Vedic yoga tradition. She has been teaching therapeutic restorative yoga therapy since 2001. Kaya's work is healing, transformative, deeply rejuvenating and empowers her student and clients with wisdom and inner experience. Her trained in the full spectrum of the Vedic Tradition includes Yoga, Yoga Therapy, Prenatal Yoga, Ayurveda, Women's Health, Eastern Anatomy, Sanskrit, Vedic Astrology and Vedanta Philosophy. She collaborates with her husband Michael Manzella, a Vedic Astrologer, to serve yoga students and teachers who are inclined toward depth of inner experience and knowledge. MORE ON KAYA

About
SRY
Ayurveda
Work with Me
Audio
Contact
- Resources