Mindful Grieving Yoga Therapy: Participant Information Form

Thank you for your interest in the Mindful Grieving Yoga Therapy series. Please fill out this form to the best of your ability. Your answers will be kept confidential and read only by our lead teacher, Corinne Andrews, in preparation for the course.

Name

First Name

Last Name

Date

YYYY

Phone

(###)

###

####

Is it ok to leave a private message on voicemail?

What is the best way to contact you?

Marital Status

Emergency Contact

Please provide the name, email, and phone number of someone we can call in case of an emergency.

What are your pronouns?

Birth Date

What is your occupation?

Do you have any children?

If yes, do your children live at home?

What kind of loss have you experienced?

Examples: Relationship, Parent, Friend, Grandparent, Pet, Job, Identity, Collective grief, Other

When did this loss(es) occur?

Have you ever participated in a GSN Yoga Therapy Program in the past?

Are you currently in therapy?

What is your current support system?

Have you experienced any events that you would consider traumatic, whether related to this loss or not?

Have you ever attempted or considered suicide?

Are you currently taking any medications for depression, anxiety, or other mental health issues?

Have you ever been hospitalized for psychiatric reasons?

Do you experience fighting in your household?

Do you currently practice yoga?

Are you currently pregnant?

Do you have any injuries or disabilities that will affect your practice?

Why are you interested in participating in this program?

How did you find out about this program?

Anything else you'd like us to know?