Yoga Therapy Initial Evaluation & Plan of Care

Note Type: Yoga Therapy Initial Evaluation & Plan of Care

Client Name: [Client full name]

Date of Birth: [MM/DD/YYYY]

Date of Service: [MM/DD/YYYY]

Start/Stop Time: [HH:MM – HH:MM]

Location: [in-person / telehealth]

Practitioner: [Name, credentials (e.g., C-IAYT and any licensed credentials)]

Referring Provider: [Name, credentials, organization] (Include only if applicable)

Consent & Scope

[Consent status] (Include only if not documented elsewhere. If obtained via intake paperwork, state that consent is on file, risks/benefits were reviewed, and the client verbalized understanding. Clarify that yoga therapy is educational and supportive, not a substitute for medical or mental health care, and that medical information is client-reported. If touch assists are part of the practice model, document consent status; otherwise omit.)

Reason for Visit

Chief Concern: [Primary concern in client-centered language]

[History of presenting concern] (Summarize onset and course; symptom descriptors including location, quality, intensity; aggravating and alleviating factors; relevant 24-hour pattern; impact on work, ADLs, and participation; prior treatments and responses; current self-management strategies; client goals for yoga therapy. Conclude with client priorities or values-based motivators likely to influence adherence and practice design.)

Health History & Safety Screening

• Relevant medical conditions: [Client-reported conditions affecting safe practice, including cardiovascular, neurological, musculoskeletal, pulmonary conditions, pregnancy status, recent surgeries, and restrictions]
• Medications affecting practice: [Name, class, or effect if relevant to exercise tolerance or safety]
• Current activity level: [Brief description; include formal screening tool and result if used]
• Behavioral health considerations: [Trauma history, panic, or dissociation risk] (Include only if relevant to planned breathwork or meditation)
• Red flags identified: [Findings and actions taken] (If none, state "None identified" or omit)
• Unknown safety-critical information: [Missing items and how plan accounts for uncertainty] (Include only if applicable)

Precautions & Modifications

• [Precaution: Condition or risk factor — what to avoid — planned modification or monitoring]
• [Practice boundaries if any: e.g., avoid breath retention, modify inversions, cap intensity at specified RPE range]

(If no precautions identified, state: No precautions identified.)

Baseline Measures

(Include at least one symptom baseline and one functional baseline tied to goals. Use validated instruments when feasible; otherwise use 0–10 scales with defined anchors. Common domains below; include only those relevant to this client.)

• Pain: [Instrument and score, or 0–10 intensity and interference ratings]
• Sleep: [Instrument and score, or 0–10 quality with continuity details]
• Stress: [Instrument and score, or 0–10 rating]
• Fatigue/Energy: [Instrument and score, or 0–10 rating]
• Breathing symptoms: [Instrument and score, or dyspnea rating at rest/exertion]
• Functional capacity: [Domain and quantifiable baseline, e.g., sitting tolerance, walking distance, work/ADL participation]
• (If a relevant measure was not assessed, note: Not assessed — [brief reason])

Objective Assessment

• General observations: [Affect, posture, gait if observed, respiratory effort at rest]
• Movement screening: [Key limitations; balance; movement quality; pain behaviors; symptom response to movements]
• Breath assessment: [Pattern at rest; predominant region; cadence; nasal/oral; ability to modulate; symptom provocation with breath awareness]
• Regulation/attention capacity: [Window of tolerance, attention span, cueing needs] (Include only if relevant to planned practices)

(Do not include vitals unless measured. Do not document normal findings that were not assessed.)

Clinical Impression

[Synthesis of findings] (Summarize primary problems in yoga therapy terms: function, symptoms, self-regulation capacity; key contributing factors; precautions; rationale for why yoga therapy is appropriate now. Document client-reported diagnoses or symptoms consistent with a condition; do not infer medical diagnoses unless licensed.)

• Problem 1: [Problem name]
  • Baseline: [Link to relevant measures]
  • Contributing factors: [Brief list]
  • Precautions: [Relevant items]
  • Yoga therapy approach: [High-level plan focus]
• Problem 2: [Problem name] (Add additional problems as needed)
  • Baseline: [Link to relevant measures]
  • Contributing factors: [Brief list]
  • Precautions: [Relevant items]
  • Yoga therapy approach: [High-level plan focus]

Prognosis: [Anticipated response, expected timeframe, limiting factors]

Goals

(Co-created, meaningful, measurable, and time-bound. Include at least one functional/participation goal and one symptom/self-regulation goal.)

Long-Term Goals (Episode of Care)

Goal	Measure	Baseline	Target	Timeframe
[LTG 1]	[Validated instrument or functional metric]	[Value]	[Target value]	[e.g., 8–12 weeks]
[LTG 2]	[Measure]	[Baseline]	[Target]	[Timeframe]

Short-Term Objectives

Objective	Measure	Baseline	Target	Timeframe
[STO 1: skill acquisition or adherence target]	[e.g., practice frequency, technique proficiency]	[Baseline]	[Target]	[e.g., 2–4 weeks]
[STO 2]	[Measure]	[Baseline]	[Target]	[Timeframe]

Plan of Care

• Service parameters: [Visit frequency], [Total duration or number of visits], [Session length in minutes], [Reassessment interval]
• Planned in-session interventions:
  • Movement-based practices: [Emphasis areas such as mobility, strength, balance; regions of focus]
  • Breath practices: [Approach such as lengthened exhale, nasal breathing, paced breathing]
  • Meditation/mindfulness: [Type and duration]
  • Relaxation techniques: [e.g., body scan, guided relaxation]
  • Education topics: [Key topics such as pacing, posture, pain neuroscience, sleep hygiene]
  • Self-management coaching: [Adherence strategies, habit formation, tracking]
  • Props/adaptations: [Equipment and environmental adaptations needed]
• Home practice prescription (Required):
  • Practices: [Specific movements, sequences, breath practice, meditation/relaxation]
  • Dose: [Minutes per session], [Frequency per week]
  • Intensity guidance: [Target RPE range or symptom threshold; acceptable symptom response]
  • Precautions: [What to avoid; modifications; stop rules]
  • Progression criteria: [When and how to advance]
  • Tracking method: [Log, app, or handout; what to record]
  • Flare plan: [What to do if symptoms worsen, including stop rules and modification options]
  • Materials provided: [Handouts, video links, access instructions]

(If no home practice is appropriate, document the clinical reason and when this will be reassessed.)

• Care coordination: [Referrals made; provider communication; medical clearance status] (If clearance pending, note plan is contingent on clearance and list interim low-risk practices permitted)
• Education delivered today: [Key points taught; client response or teach-back]
• Follow-up plan: [Next visit timing], [Planned focus]

Session Response

(Include only if practices were trialed during evaluation; otherwise omit this section entirely.)

• Interventions trialed: [Brief list]
• Client response: [Tolerance; symptom changes; emotional response]
• Disposition: [Left in stable condition / symptoms returned to baseline / other]

Signature

Practitioner Signature: [Name, credentials, date and time signed]

Supervising Clinician Signature: [Name, credentials, date and time signed] (Include only if required by organizational policy)