YOGA THERAPY REFERRAL FORM

Name

First Name

Last Name

Date of Birth

Phone

(###)

###

####

Referring or current Physician Name addressing your yoga therapy need , Telephone number

write "self" if its self referral

Referral for:

Does your doctor/healthcare practitioner know that you are participating in Yoga Therapy? if Yes,

yes

Collaboration among healthcare providers can lead to a more successful outcome and thorough approach to your care. May we have your permission, if needed, tocontact other members of your healthcare team?

yes

What are your primary reasons for coming in for Yoga Therap

Please share if you have diagnosis, conditions, surgeries that you are seeking yoga therapy for. Be detailed and specific to the condition to best plan your yoga therapy

Do you currently practice yoga? (If yes, please include the following) How often & which style? Do you practice at a studio? Do you have a home practice? What do you find is the most challenging?

Is there now or has there historically been any illness or physical challenges which may impact your Yoga practice? Please share below:

Please share any/ previous experience with yoga, meditation, complementary, alternative health and healing. Include by describing your level of physical activity with any exercise regimen you do.

Is there anything that surfaced during a recent medical test, lab work, or doctor’s visit that you would like to report?

Any surgery, acute, or chronic illness? (Please list)

How would you describe your overall health?

List your medication(s) that you are currently taking

Include vitamins and herbs

Do you smoke, vape or use cannabis?

please describe how long and how often and how much use daily or occasion.

Do you drink alcohol?

Please include how much and how often, include if you are in sobriety and how long or on meds for chemical dependency

Dietary Intake

Include some information on the following: Do you eat regular meals? How much caffeine do you consume in a day? How much water do you drink in a day? (Oz.) Any food allergy, sensitivities or intolerances?

How would you describe your overall mood and energy level?

Include if you are experiencing any of the following ; Anxiety , Fear , Sadness, PTSD, Depression, Grief, Despair Negative Self-Talk , Anger, Other Emotions

Do you have any current or chronic ongoing pain/discomfort/stiffness

Please include to share Does anything make your pain/discomfort better? Does anything make your pain/discomfort worse? Is there a daily pattern to your symptoms? Do you experience any of the following in your body?: Stiffness ,.Weakness, Discomfort Tightness, Decreased Mobility , Excess Mobility , Fatigue or Decreased Endurance, Limitations in Daily Activities

Which aspects of your life give you the most joy and pleasure? Briefly describe your passions and interests? How do you express yourself creatively? Please describe your Spiritual Practices and Beliefs.

Share your Stress Response & Coping Strategies

Please include to share On a scale of 1-10, with 1 being low and 10 being high, how stressful is your: Work: Social/family situation: Current health status: Life in general: What strategies do you use to manage stressful and emotional situations? Do you have people in your life in which you can confide or go to for counsel? Is there anything about your family relationships that you would like to share?

Is there anything else you would like to ask me?

write none. if finish.

Disclaimer

A variety of yoga interventions may be used for chronic conditions and and oncology patient , such as sitting in a chair or resting flat . Below is a brief explanation of yoga interventions: Awareness practice. Mental inventory of patient’s own body . The patient is encouraged to allow him- or herself to feel and sense the present moment without changing anything. Breath practice (three parts). Three parts of the breath practice include the abdomen, diaphragm, and chest. Patients are instructed to completely fill their lungs with air, as though breathing into their belly, rib cage, and upper chest, and then exhale completely, reversing the flow . Movement: head and neck series. Patients move their head and neck through its range of motion: turning the head side to side, dropping ear to shoulder, dropping chin to chest, and rolling shoulders forward and back Movement: seated cat-cow. In the cat posture, the spine is rounded like an angry cat. In the cow part of the posture, the spine bends downward, opening the chest and stretching the abdomen . The gentle movement and stretching, coordinated with the breath, relieves stress and tension by calming the senses. (A contraindication of these postures would include bone metastasis.) Yoga nidra. Also known as “yogic sleep,” yoga nidra is a deep relaxation technique and a form of meditation. The body is completely relaxed and the practitioner turns his or her awareness inward by listening to a set of instructions, much like a guided meditation. Guided imagery. A mind-body intervention in which a trained practitioner helps a participant to evoke and generate mental images that simulate or re-create the sensory perception of sights, sounds, tastes, smells, movements, and images.

Waiver and Liability and Consent

I hereby agree to the following: It is my choice to receive yoga therapy ( therapeutic yoga) . I understand that the practice of yoga therapy is provided for the well being of my body and mind, and in no way takes the place of a doctor’s care when it is indicated. I acknowledge that yoga therapy is not a substitute for a medical examination or diagnosis, and that it is recommended that I see my primary health care provider for that service. Information exchanged during any yoga therapy session is educational in nature and is intended to help me become more familiar and conscious of my health status and is to be used at my own discretion. Yoga therapy sessions may be offered in a physical location or offered online by video or using other digital media or platforms. All of such offerings, either physical or online, shall be considered “Activities.” I recognize that I must be in adequate physical and mental health to participate in the Activities. I understand that the Activities may involve physical exertion and I represent and warrant that I am physically fit enough to participate, and have no medical condition which would prevent my full participation in the Activities. If there is any doubt in my ability to participate in the Activities, I understand that it is my responsibility to consult with a physician prior to and obtain permission from my physician regarding my participation in the Activities. If I have done so, I have taken the physician’s advice. I understand that the instructor reserves the right to refuse my participation in any Activity on medical, fitness or any other grounds. Furthermore, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in these sessions. I agree to inform my instructor of any physical limitations, physical discomfort and/or injuries before or during classes, and I take full responsibility for any nondisclosure. Therefore, I acknowledge that participation in this program may involve some risk of physical injury due to the nature of the activity. In consideration for my acceptance in this program, I do hereby release and forever discharge, for myself, my heirs, executors and administrators, any and all claims to collect damages against Christina Martini Yoga & WellnessLLC, and Shala Santosha Astanga Yoga & Wellness, Maui Cancer Advocare, LLC. or representatives, employees, agents or officials, directors or sponsors. I further represent that I am in good physical condition and, as such, am able to participate in this program. I promise to practice yoga mindfully. I have read the above waiver of liability and fully understand its contents. I voluntarily agree to all its content and to the terms and conditions stated above. 24-HOUR CANCELLATION POLICY Because your appointment time has been reserved especially for you, clients are required to give a minimum of 24 hours notice when cancelling an appointment, at which time the appointment can be rescheduled at no charge. Sessions cancelled with less than a 24-hour notice will be charged the full session rate.

Let's Get Started. The benefits of therapeutic yoga are vast and range from greater strength and balance to an improved heart rate variability (HRV) and increased mental clarity. Growing research supports the efficacy of the therapeutic yoga in reducing symptoms of depression, anxiety, post traumatic stress, cancer treatment side effects and more.

Yoga is inherently therapeutic, but there is a clear distinction between a yoga class and a yoga therapy session. Although both yoga teaching and yoga therapy are valuable, the scope of practice is different. Yoga therapy is a complementary and integrative therapeutic approach that may provide useful information on contraindications and comorbidities. Ultimately, yoga therapy is self-empowering and includes careful guidance and application of the proper tools by a fully trained yoga therapist using the methods of yoga to potentially restore health.

If you are interested in integrating Therapeutic Yoga into your patient’s care plan, personalized Integrative Postures, Breathwork, And Meditation and Wellness Modalities email or call Christina Martini 714 488 0623

How To Refer To Therapeutic Yoga?

Simply complete the referral form above and submit or give patients A Script or Rx and write “Therapeutic Yoga” with your special instructions. When the yoga therapist receives the referral, An assessment will be performed and progress note for your patient’s file will be sent. Clients can often use their health savings accounts, flexible spending accounts, and other such accounts as well or if insurance does not have benefits for such services, pay out of pocket, self pay for yoga therapy services. We do not bill at this time for services.

Christina Martini has years of practice specializing in Yoga Therapy for health and pre existing conditions, clinical diagnosis and preventative measure. She has years of hands on applied knowledge and experiences in patient and outpatient health care settings; oncology (chemo/radiation/immuno therapy/clinical trials) primary care, medical surgical pre and post surgical recovery and rehabilitation and physical, recreational, occupational therapy. This level of experience consisted of years of formal rigor of clinical training and continuing education along with meeting science competencies, clinical hours, anatomy, physiology, pharmacology knowledge, disease process, pre and post operation clinical knowledge, nursing assessments, and practicum of 20 + years working along side medical providers, surgeons, physical and occupational therapists and alternative integrative medicine, naturopath, eastern medicine and many other adjuvant therapies. She is a certified patient advocate/navigator, delivering professional practice with clients that need support through hospice, palliative, end of life comfort measures, and current with HIPAA, ACLS, BLS and CPR.

What happens in a yoga therapy session?

During a yoga therapy session, the yoga therapist will work with you to create a personalized care plan for your personal practice that is designed to help you reach your health goals. Working one-on-one with a yoga therapist can be particularly useful for people who are new to a yoga practice and those who have health challenges.

Each Session will include:

1. Assessment. The initial session is 60-75-90 minutes and begins with an in-depth conversation designed to help the yoga therapist understand your health challenges, history, concerns, interests, and goals. Intake Health and Physical information is gathered.

2. Breathing and movement instruction. You will be guided through some simple movement and breathing practices to assess your strength, flexibility, and balance as well as your habits of body and mind.

3. Care Plan of your personalized practice. The yoga therapist will create a personalized yoga practice designed to suit your abilities, health goals, medical challenges, interests and time. This may include postures, breathing techniques, and meditation, as well as the application of yogic principles such as gratitude and non-harming.

4. Practice instruction. After guiding you through your practice, the yoga therapist will provide materials (handouts and sometimes audio and/or video recordings) to help you practice regularly at home. Suggested practice independently is everyday if possible 20-30 min a day.

5. Return sessions. Follow-up sessions are 60 minutes and will help refine your practice and as you become more confident—and/or your needs and conditions changes— other offer of modifications and/or new material will be added to your care plan.

It’s important to recognize that, while yoga has great power to heal, it only works if you have a consistent practice like medications. It is natural, potent and healing! Because regular practice is essential to gain and witness and feel the benefits of yoga, it’s helpful to plan your day with prioritizing the right time for your yoga therapy session and also the right time for three to six days of yoga practice at home . After the initial period, some individuals enjoy having regular sessions, monthly or weekly. Others return for occasional “follow-up - reassessment” visits.