Initial Intake Form


This intake form is to help us craft your program as effectively as we can to address your concerns and lifestyle.
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1.  
First & Last Name
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2.  
Email
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3.  
Skype Name
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4.  
Phone Number to Be Reached At
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5.  
Address
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6.  
What are your primary interests in ayurveda? Please select your interest level.
Nutrition

Cleansing

Health Issue

Lifestyle

Supplements/Herbs

Meditation/Yoga

Weight Loss

More Energy

Stress Reduction

Spa Treatments

Self-care & Beauty

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7.  
Describe your physical health and list any concerns or areas you would like to improve
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8.  
What interests you in committing to an ayurvedic program?  What do you hope to gain from working with Monica?
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9.  
What is your personal definition of health?
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10.  
What are your obstacles that prevent you from living a healthy lifestyle that you describe?
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11.  
 What are your obstacles when it comes to living the healthy lifestyle you want?
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12.  
How do you see your self-study, ayurveda and yoga playing into your current life right now?
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13.  
Have you ever embarked on a health or lifestyle program in the past?
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14.  
Did you complete the program as intended? If no, can you describe what held you back from completing the program?
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15.  
Do you cook most of your meals?
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16.  
What did you eat for breakfast, lunch, dinner, snacks and drinks over the past 3 days?
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17.  
What time do you eat your breakfast, lunch and dinner?  Do you feel hungry at those times?
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18.  
Are you willing to change your diet?
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19.  
Do you get a good night sleep each night?
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20.  
What time do you typically go to sleep at?  What time do you wake up? Do you feel like you get enough sleep?
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21.  
Do you sleep through the night?
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22.  
Describe a typical day:
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23.  
Do you enjoy what you are doing with your life? Do you feel purposeful?
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24.  
What is your current stress level like? 
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25.  
Please list herbs, supplements, or medications that you are taking and why.
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26.  
Please check any symptoms that apply:
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27.  
Are you taking any of the following?
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28.  
Initial Consultation Informed Consent

1.    The goal of this program is to increase harmony within your body and mind using the principles of Ayurveda.

2.    Monica Yearwood is not trained in western medical diagnosis or treatments.  She is not a physician, nor a licensed health care professional.  Rather, she is an Ayurvedic practitioner using Ayurveda.

3.    Monica has trained at Maharishi Universion of Mgmt., The Florida Vedic College, Ayurvedic Center in Sarasota, FL., The California College of Ayurveda, Rasayana Cove Center in Arcadia, FL., Sri Swamini Mayatitananda and Linda Sarita Rocco.

4.    If you are suffering from disease or severe symptoms, you must be evaluated by a medical doctor.  If you choose not to see a medical doctor, you will have to sign an acknowledgement that one was recommended to you.

5.    Hamsa cannot alter your medications.  If you decide to use herbs or supplements, you must seek approval from your doctor.  Hamsa holds no liability for any herbs, oils, or supplements and any reactions that they may cause.

6.    While we understand you may have questions about your program and we are happy to answer them, if we feel that the questions are beyond the scope of your program and require an additional session we will advise you to meet with Monica Yearwood, Hamsa's founder, and additional fees may apply.

7.    For information about appointment, treatment, or panchakarma cancellations, please view our cancellation policy that was e-mailed to you at the time of booking or contact info@hamsacenter.com for assistance.

8.    All payments for herbs and supplements are due upon order.  Please be mindful that if personal blends have been made for you, especially medicated ghees and oils, they will take a few days longer to be shipped.  Products are made by hand and specifically for you.  Some blends may take 4-36 hours to make.  We will do or best to get them as soon as possible and provide suitable alternatives in the interim.

9.    Please be mindful of all appointment times.  If you are late, the full duration of your appointment cannot be guaranteed.  Please see our cancellation policy for further clarification or contact info@hamsacenter.com for assistance.

10.    If you require more time than what is allotted in the initial/follow consultation booking, we will do our best to accommodate you.  Should you require additional time, please e-mail info@hamsacenter.com to schedule.  The rate for additional time is $250/hr and is due at time of booking.