Home Practice Plan (Yoga Therapy)

Client Name: [Client name]

Date of Birth: [DOB or age]

Plan Date: [Date plan created]

Version: [Version number] (Include "Revised from [previous date]" if this is an update)

Yoga Therapist: [Therapist name, credentials, organization, contact method]

Developed from session on: [Encounter date that generated this plan]

Plan Summary

Goals: [1–3 functional aims in client-friendly language, e.g., reduce morning stiffness, support calmer breathing during stress, improve sleep onset]

Preferred practice: [Duration in minutes], [frequency as days/week] (Include time-of-day suggestion only if clinically meaningful)

Minimum practice: [Shorter duration], [minimum frequency]

Review in: [Weeks until follow-up]

Safety & Precautions

Practice within your comfortable range. Do not push into pain. Stop if you feel dizzy, lightheaded, or short of breath beyond expected gentle exertion. Move slowly in and out of positions.

Client-specific precautions: (Include only if applicable; omit heading if none)

• [Condition or consideration]: [Affected practices] — [Required modification or alternative]

(If medical history was not provided or is incomplete, include the following statement:) Medical history not provided — please inform your yoga therapist of any conditions that may affect your practice.

Stop and Contact

• Stop immediately and seek medical help if: chest pain, fainting, or new neurologic symptoms such as sudden weakness or numbness.
• Contact your yoga therapist before continuing if: symptoms worsen or persist more than 24–48 hours, new joint swelling, or unexpected pain.

This plan supports your wellness goals and is not a replacement for medical evaluation. If you have health conditions, share this plan with your healthcare team.

Practice Sequence

(Present as a numbered list flowing through: arrival/centering, warm-up/mobilization, main targeted practices, cool-down/downregulation, and brief closing. Address the client as "you." Include as many steps as prescribed.)

1. [Practice name in English (Sanskrit optional)]

   Purpose: [One short phrase in client language]

   Dose: [Time, breaths, or repetitions]

   Key cues: [1–3 concise instructions]

   Modification: [Specific adjustment] (Include only if applicable to this client)

   Safety note: [Pose-specific stop rule] (Include only if applicable)

2. [Practice name]

   Purpose: [One short phrase]

   Dose: [Time, breaths, or repetitions]

   Key cues: [1–3 concise instructions]

   Modification: [Specific adjustment] (Include only if applicable)

   Safety note: [Pose-specific stop rule] (Include only if applicable)

3. [Breathing practice name] (If prescribed; specify exact technique—avoid vague terms like "pranayama")

   Purpose: [One short phrase]

   Dose: [Duration in minutes and/or number of rounds]

   Pacing: [Inhale count : exhale count : hold if applicable]

   Key cues: [1–3 concise instructions]

   Modification/Safety: [e.g., reduce counts, skip retention, upright posture] (Include only if applicable)

4. [Guided relaxation/meditation name] (If prescribed)

   Purpose: [One short phrase]

   Dose: [Duration in minutes]

   Key cues: [1–3 concise instructions including a simple closing cue to transition back]

As-Needed (PRN) Practices (Include only if prescribed; omit section if none)

• [Micro-practice name]

  When to use: [Trigger or symptom flare]

  How often: [Maximum frequency and duration per use]

  Key cues: [1–2 concise instructions]

Resources: [Handout or video reference, e.g., "See Video #3 for demonstration"] (Include only if provided)

Tracking

What to track: [Minutes practiced, days completed, symptom rating 0–10 before and after practice, other minimal metrics if relevant]

When to track: [Immediately before and after practice] (Note next-day response if delayed flares are relevant for this client)

How to track: Use the attached log, a calendar, or a simple daily check-in.

If your symptoms increase by 2+ points and last more than 24 hours, reduce to the minimum practice and contact your yoga therapist. If symptoms improve steadily, maintain the current plan for 1–2 weeks before considering progression.

Next review: [Date or timeframe]

Questions or concerns: Contact [Therapist name] at [Contact method].

Chart Addendum

(For clinical record only; do not include in client handout. Omit this section entirely if no chart-level documentation is needed.)

• Clinical indications: [Brief rationale for selected practices based on presentation and goals]
• Progression criteria: [Specific rules, e.g., "Increase by [increment] when symptoms ≤[value] for [days]; hold or regress if symptoms increase ≥2 points for >24 hours"]
• Coordination notes: [Communications with referring provider; relevant medical guidance integrated] (Include only if applicable)
• Teach-back confirmation: [Client demonstrated understanding of key steps and stop rules; note any return demonstration]
• Safety data: [Vitals or contraindications if assessed] (State "not assessed" or "not provided" for safety-critical unknowns rather than leaving blank)