Intake Form | Ride the Wave Yoga

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Client Intake Form for Individual Consultations

Ride the Wave Yoga is a Limited Liability Company accredited by the State of Massachusetts. Please take the time to fill out the information below electronically. All information is kept strictly confidential.

Basic Information

1. First Name

2. Last Name

3. Gender Pronouns

4. Email

5. Address

6. Phone

7. Marital Status

8. Employer/ School

9. Parent or guardian (if under 18)

10. Who referred you?

11. May Ashley acknowledge the referral?

Yes

No

12. Emergency contact name

13. Emergency contact number

14. Relationship to you

15. What best describes why you are interested in a private session? (Please check all that apply.)

To expand an awareness of my life's purpose or direction

To improve the quality of my relationship to self and others

To learn how I can use yoga and/ or astrology as a tool for my own self growth

To gain insight into my present circumstance or current life cycle

To understand my physical, mental or emotional health imbalances

16. Please expand on the above in as much detail as possible.

Health History

17. Have you ever been treated for depression/ anxiety?

Yes

No

18. Are you or have you been in the care of a therapist or psychiatrist?

Yes

No

19. If yes, with whom and when?

20. May Ashley have permission to contact this person?

Yes

No

21. Do you or have you had suicidal ideations?

Yes

No

22. Do you or have you had homocidal ideations?

Yes

No

For Astrological Consultations Only

23. On a scale of 1-5 (5 being very), how familiar are you with the practice of astrology?

26. Birth date (If you prefer not to enter your birth information online, you may call Ashley with your birth date, place and time instead.)

24. Have you ever had your natal chart read before?

Yes

No

27. Birth time (An accurate birth time will greatly enhance the amount of information available during the reading. If you are unsure of your correct birth time, please check your birth certificate or contact your birth hospital or city.)

25. If yes, how satisfied were you with that reading (5 being very)?

28. Birth place

Terms of Confidentiality

It is the policy of Ride the Wave Yoga LLC to protect the privacy of the information shared during private sessions to the maximum extent possible. Information about you or services provided to you will not be released without your prior verbal consent. There are, however, some circumstances which require the disclosure of information without your consent, such as when:

a.) mandated by state or federal law due to suspicion or knowledge of child abuse and/or neglect or elder abuse and/or neglect,

b) there is an imminent risk or serious threat of physical harm to self or to others, and

c) specifically ordered by a court of law.

29. I agree to the Terms of Confidentiality. *

Thanks for submitting. Ashley will be in touch soon.

Free street parking all day and complimentary parking in the Professional Building lot located cross the street on weekends and weekdays after 5p.m.

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12 Maple Street

Newburyport, MA 01950

Web design by Ashley Leone

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