Yoga with Kaya Resources
About
SRY
Online Followup for Teachers
Online Followup for Teachers
Audio SRY Practice with Kaya
SRY Fundamentals Course
Sharing SRY
Agni and Soma Home Study
YTT in SRY
Ayurveda
Join Agni and Soma Nutrition
Tridoshic Food List
Ayurveda Application
Ayurveda Followup
Yogify
Māyurveda
Māyurveda Intake
Early Pregnancy
Mayurveda Conception Client Pages
Māyurveda Prenatal Client Pages
Mayurveda Postpartum Pages
>
Kids Ayurveda
Work with Me
Retreat Intake
Training / Mentoring Intake
One on One Intake
Audio
Shavasana
Bhagavad Gita Essentials
Contact
Resources
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?
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Yes, something I can do quickly to relieve pain
Yes, something I can use as a deep body-mind practice
Not yet, but maybe in the future
No, I do not want to do a home practice, ever!
Other {expand below}
Please describe your MEAL TIMES and what you eat? Also include snacks, drinks, coffee, tea, etc.
*
Group Classes
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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?
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Yes, highly motivated to do better self care
I'm already pretty good about this, and have this covered.
I'm curious and not sure
Other {expand below}
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
About
SRY
Online Followup for Teachers
Online Followup for Teachers
Audio SRY Practice with Kaya
SRY Fundamentals Course
Sharing SRY
Agni and Soma Home Study
YTT in SRY
Ayurveda
Join Agni and Soma Nutrition
Tridoshic Food List
Ayurveda Application
Ayurveda Followup
Yogify
Māyurveda
Māyurveda Intake
Early Pregnancy
Mayurveda Conception Client Pages
Māyurveda Prenatal Client Pages
Mayurveda Postpartum Pages
>
Kids Ayurveda
Work with Me
Retreat Intake
Training / Mentoring Intake
One on One Intake
Audio
Shavasana
Bhagavad Gita Essentials
Contact
Resources