Yoga1 Eating Disorder Intensive with Ana Forrest & Barbara Ruzansky August 18 – 23, 2006

westhartfordyoga1


Eating Disorder Intensive with

Ana Forrest & Barbara Ruzansky

August 18 – 23, 2006
Application Questions
Please type your answers to the following (if you are using MS Word or a compatible program, you can simply type each answer after each question), sign and date the bottom. Include a current photo of yourself and a deposit of $300. Mail to West Hartford Yoga, 32 Jansen Court, West Hartford, Ct. 06110.

PERSONAL PROFILE:

1. 
   Name, Address, City, State, Zip
   
2. 
   Telephone numbers (Home, Work , Fax, Cellular) and e-mail address
   
3. 
   Occupation, Gender, Date of Birth
   
4. 
   Activities, Hobbies, Interests
   
5. 
   Who can we call in case of an emergency?
   
6. 
   Would you like to receive updates about Forrest Yoga & West Hartford Yoga products and events?
   

INTEREST IN YOGA:

1. 
   How did you hear about the Eating Disorder Intensive?
   

_____Website ____Yoga Journal ____ Brochure _____WHY studios
_____Conference _____Workshop _____Mental Health/Medical Provider

_______________Other (Please specify)

2. 
   Please list any previous yoga experience (length of time, specific teachers, types of yoga).
   

3. 
   What are your expectations for this intensive? What do you hope to gain, learn or work on?
   

4. 
   Tell us about your physical health (major illnesses, surgeries, any injuries or physical conditions that we should know about?) Indicate if your condition may result in early withdrawal from the program when you contact West Hartford Yoga.
   

5. 
   Are you currently taking any medications? If yes, please describe.
   

6. 
   A) Tell us about your history with eating disorders, including therapies, medications, hospitalizations, etc.
   

2. 
   Describe your current condition relative to your eating disorder. E.G: Are you actively anorexic or bulimic? Are you currently in therapy? Are you able to work and take care of yourself? Add anything else about your current condition that you feel is pertinent.
   
3. 
   What involvement do your parents and family have regarding your eating disorder?
   

7. 
   Tell us about any other emotional and mental health issues you have had (depression, addictive behaviors, etc.) and any treatments you have sought for these conditions.
   

8. 
   Have you ever been physically, sexually, or emotionally abused or assaulted? Have you had any experience with violent behavior? If so, please describe.
   

9. 
   A) Tell us about your diet, health, and exercise practices and beliefs.
   

2. 
   Describe your daily diet in detail. Include what foods you eat, what you do not eat, how often you eat, how much you eat.
   
3. 
   List everything you ate yesterday.
   
4. 
   List any food allergies or food sensitivities you have.
   
5. 
   What are your food preferences? (ie: vegetarian, vegan, high-protein diet, carnivore, non-dairy, etc.)
   

10. 
    List any other interesting things you think we should know about yourself.
    

11. 
    Tell us your hopes and fears about moving towards a healthier life. Please ponder this, and answer truthfully and profoundly.
    

12. 
    Are you willing to heal? Are you willing to work for it?
    

_________________________________ _________________

Signed Date

After we receive your application and deposit you will receive a packet including information on housing, things you will need to bring, and other pertinent details.

West Hartford Yoga, L.L.C. Barbara Ruzansky, Director

32 Jansen Court (860) 953 YOGA (9642)

West Hartford Ct. 06110 www.westhartfordyoga.com