Intake Session
Date: 12/19/2023 2:30-4:45 pm

Intake summary:
The intake session was conducted on 12/19/2023 via Zoom. KKO is a 74-year-old Asian female who relocated from Japan to Northern California in 1979 due to her husband’s job transfer. She does not work and lives with her retired husband, whereas her adult children and grandchildren live elsewhere in California but often visit them.

Her primary objective for participating in yoga therapy is to improve respiratory health. In January 2015, she contracted pneumonia, which developed an infection by nontuberculous mycobacteria (NTM), specifically mycobacterium avium complex (MAC). The resulting MAC lung infection caused inflammation and irreversible changes to the airways, including damaging and scarring her right lung. Since her total lung capacity decreased, she suffers shortness of breath during physical activities and experiences fatigue, excess mucus, and frequent coughs to clear the congestion. She experiences heart palpitations when walking uphill, during vertical movements of the body, and when changing her body position quickly, such as rising from a lying position. She has been managing the challenges “fairly well” by moving slowly and limiting the number of activities she plans for a day to avoid energy depletion. Nonetheless, she understands MAC presents certain predisposing risk factors to develop additional respiratory illnesses like the flu, pneumonia, and COVID-19, which induce worries and stress in her. She suspects stress exacerbates the contact dermatitis around her neck, which has become more frequent lately.

Her source of joy is family, spending time with her children and grandchildren, and traveling. She enjoys many hobbies, including Japanese calligraphy and gardening. She left her local choral group in May due to her breathing challenge, which she feels was the right decision. Keeping up with others and not distracting the practice with coughing has been another cause of stress. She is not undergoing respiratory therapy, only a routine check for pneumonia. She recognizes the need for moderate exercise for maintaining respiratory health. Her weekly regimen includes tai chi and hatha yoga class on Zoom and walking for one hour with friends. KKO has been a regular student in my beginning yoga class for over two years. She is interested in establishing a regular meditation practice, although she “may not be good at it.” She does not like to keep a journal out of fear that someone else might read it later.

Assessment:
KKO’s lung capacity and respiratory health have been impacted by the lasting side effects of MAC infection for the last eight years, affecting Annamaya and Pranamaya Kosha. Manomaya Kosha is also impacted due to anxiety and stress associated with episodes of shortness of breath and heart palpitation. She scales back her otherwise active and social lifestyle due to the limitations, sometimes forgoing outings with grandchildren, which makes her sad. The unknown trajectory of the illness also causes stress and uneasiness as she moves toward the last decades of her life, negatively impacting Manomaya and Anandamaya Kosha. Misidentification with the illness is suspected in Vijnanamaya.

Based on the breath assessment in seated and spine positions, paradoxical breathing, mouth breathing, and breath-holding were absent. KKO was able to perform deep breathing by voluntarily expanding and contracting the diaphragm. She was able to hold her breath for 23 seconds per minute, whereas a regular breather can hold for 30 seconds.

She presents excellent postural awareness and alignment, considering her age (74). No scoliosis or kyphosis was observed. She coughed occasionally to clear her throat but presented no shortness of breath during the gentle asanas and breathing assessment. She was highly coherent and followed the instructions with complete focus.

Guna assessment suggests she is relatively well-balanced in a sattvic state, which is supported by her optimism, creativity, and ability to appreciate moment by moment with mindfulness despite her physical limitations. Easily depleted energy (Alasya) and the disease (Vyadhi) are two obstacles to the practice (Antaraya), primarily for asanas.

She will work on the pranic flow by addressing prana vayu. Stimulation of the parasympathetic nervous system via extended slow exhalation will be the emphasis of pranayama. As the expiration is governed by this branch of the autonomic nervous system, it may help improve the efficiency of respiration.

Agreed-Upon Goals:
My client will…

Short-term: Learn how to relax tension in the respiratory muscles and natural diaphragmatic breathing patterns and other yogic breathing techniques to promote efficient respiration
Long-term: Work to improve a sense of freedom/spaciousness by learning how to counter the psychological stress and anxiety associated with living with chronic pulmonary illness

How yoga therapy can support my client:
• Cultivates greater interoceptive awareness through mindfulness practice. A fundamental understanding of the mechanics of the respiratory system also promotes self-efficacy (Annamaya, Pranamaya, Manomaya, and Vijnanamaya)
• Relaxes muscle tension in the respiratory muscles and creates lightness in the uppermost chest (Annamaya, Pranamaya, and Manomaya)
• Encourages natural diaphragmatic breathing patterns to promote oxygen absorption and carbon dioxide elimination, which optimizes oxygen intake to enhance endurance (Annamaya, Pranamaya)
• Improves sense of spaciousness/freedom by countering the psychological stress and anxiety associated with living with chronic pulmonary illness (Pranamaya, Manomaya, Vijnanamaya, and Anandamaya)

Considerations:
• Activities should be slow and well-paced, with multiple “breath breaks” to catch up.
• Caution during the postural transitions (e.g., supine-to-sit, sit-to-stand)
• Caution with Kapalabhati-type of breathing, and avoid if a flare-up of symptoms is present
• Caution with active back-bending asanas (Restorative is ok)
• Avoid active asana practice if coughing is present
• Ensure she is well-hydrated
• Sessions will be held in the Japanese language based on the client’s preference. Session activities and home practice are also localized in Japanese.

Planned Interventions:
Note: “+” denotes updates to the initial plans

Asana will be given to balance Annamaya, Pranamaya, and Manomaya via:
a. Freeing muscle tension in the respiratory muscles and improving muscle integrity. Primary: Diaphragm, intercostal. Auxiliary: Sternocleidomastoid, scalene, pectoral muscles
b. Gentle bridge/inversion variation to provide lightness and space in the uppermost chest. It may also help expel mucus in the chest by stretching the chest, neck, and spine upside down.
c. Restorative poses that stretch the chest, promote a sense of openness and replenish depleted energy.

Examples:
• Gentle movements with breath
o Neck flex/extension/rotation/lateral flexion
o Shoulder rotation
o Spinal lateral flexion (Crescent moon in chair/standing, Bananasana in supine)
o Spinal extension (Collarbone and Upper Chest Opening w/strap)
o Spinal flexion (Hug the knees, lift the head, seated crunch)
o Spinal rotation (Sit sideways, inhale arms up, twist)
o Cervical rotation (Head roll in supine position)
• + Sun Salutation x2 as whole-body warm-up for the Bridge/Shoulderstand to follow
• Bridge/Shoulderstand Variation
• Restorative yoga:
o Savasana
o Supported Fish (w/blanket)
o Reclining Butterfly
o Half-moon lateral stretch

Pranayama and other energy work will be given to balance Annamaya, Pranamaya, and Manomaya by:
a. Encouraging natural diaphragmatic breathing patterns to promote oxygen absorption and carbon dioxide elimination
b. Supporting efficient respiration with emphasis on engaging the parasympathetic nervous system
c. Working with Prana Vayu to optimize the pranic intake
d. Practicing tapping below the collarbones (also known as the Zhong Fu pressure point). It may relieve chest congestion, breathing difficulties, coughing problems, and anxious energy.
Examples:
• Breath Pattern Observation (in Savasana)
• Deep Breathing (in Savasana)
• The Wave. Exhale, bring the knees to the lower abdomen; Inhale, let the feet drop toward the floor, arching the lower back
• Pursed-lip Breathing. Exhalation w/abs squeeze (in Savasana)
• + Alt. Nostril breathing w/extended exhalation.
• “Prana Breath” that elongates exhalation and short retention at the crest of inhalation
• Prana vayu activation with Prana Mudra
• Below-Collarbone Tapping
• 1:2 Breathing and 1:2 Breathing with a brief retention

Meditation and other mindfulness techniques will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya by:
a. Potentially shifting how my client relates and responds to limitations and discomfort associated with living with chronic pulmonary illness
b. Supporting her with a sense of spaciousness/freedom to counter psychological stress and anxiety
c. Cultivating greater interoceptive awareness that helps inform her of the state of the body and the mind to take the necessary rest
Examples:
• Breath Awareness Mindfulness Practice
• Yoga Nidra
• Breath as Mantra Meditation
• Acoustical Mantra Meditation with personal mantra
• Meditation with Prana Mudra

Other yogic tools will be given to balance Pranamaya, Manomaya, Vijnanamaya, and Anandamaya by:
a. Cultivate self-compassion/acceptance
b. A fundamental understanding of the mechanics of the respiratory system to promote self-efficacy
c. Introduction to pranic flow and vayus
d. + Practical application of yoga philosophy

Examples:
• Practice Ahimsa via asanas and Loving Kindness Meditation (Sutra 2:35)
• Overview of mechanics of respiratory systems and key muscles for breathing, and how the autonomic nervous system influences breathing
• Overview of Pancha Vayus
• + Yamas and Niyamas
• + Prathipaksa Bhavana

1. Mac Lung Disease (Mycobacterium avium complex)
a. Overview of the disease
i. Mac Lung Disease, Cleveland Clinic
ii. How NTM MAC Affects the Body, WebMD

2. Pulmonary Disease and Yoga Intervention

a. Clinical Studies*
i. Gupta A, Gupta R, Sood S, Arkham M. Pranayam for Treatment of Chronic Obstructive Pulmonary Disease: Results From a Randomized, Controlled Trial. Integr Med (Encinitas). 2014;13(1):26-31.

“Intervention: Participants in the intervention arm (IA) performed pranayam for 30 minutes, twice per day, and received the usual medicines for COPD…Participants in the IA were trained to perform pranayam using 4 easy and effective asanas, including Suryabhedana, nadishuddhi, bhramari, and Kapil Bharti, performing each for 5 to 7 minutes.”

“Conclusion: The current study demonstrated that pranayam can be useful for individuals with moderate to severe COPD. Significant improvements in the IA’s CAT scores after 3 months of practice suggests that pranayam can improve the subjective experience of health, disease severity, and functional status for COPD patients, without much improvement in FEV1 actually occurring and with airflow limitation not fully reversible but usually progressive. The research team concluded that pranayam is a useful adjunct treatment and can be an effective rehabilitation program for individuals with COPD.”

*Note: It is cited here as COPD causes similar damage to the lungs and symptoms to MAC's. Searching for yoga AND Mac Lung Disease on PubMed did not yield any results.

ii. Apar Avinash Saoji, B.R. Raghavendra, N.K. Manjunath, Effects of yogic breath regulation: A narrative review of scientific evidence, Journal of Ayurveda and Integrative Medicine, Volume 10, Issue 1, 2019, Pages 50-58, ISSN 0975-9476, https://doi.org/10.1016/j.jaim.2017.07.008

“Conclusion:…the cost-effective and safe practices of yogic breathing could aid in the prevention and management of various communicable diseases. They may also be involved in the management of communicable diseases such as pulmonary
tuberculosis.”

iii. Zaccaro, Andrea et al. “How Breath-Control Can Change Your Life: A Systematic Review on Psycho-Physiological Correlates of Slow Breathing.” Frontiers in human neuroscience vol. 12 353. 7 Sep. 2018, doi:10.3389/fnhum.2018.00353

“Conclusions: Slow breathing techniques act enhancing autonomic, cerebral and psychological flexibility in a scenario of mutual interactions: we found evidence of links between parasympathetic activity (increased HRV and LF power), CNS activities (increased EEG alpha power and decreased EEG theta power) related to emotional control and psychological well-being in healthy subjects.”

b. Publications
i. Asthma, Yoga as Medicine by Timothy McCall
ii. “The Lungs and the Lotus Heart,” “A Bridge to Shoulderstand” -- Yoga of the Subtle Body by Tias Little
iii. “Pranayama Practices,” Yoga Therapy by Mark Stephens
iv. The Therapeutic Yoga Kit, by Cheri Clampett and Biff Mithoefer

c. Articles
i. How Yoga Therapy Works: Part 1, YogaTherapy.Health (on chemoreflex sensitivity and stress)
ii. 3 Ways to Modify Fish Pose for Joy and Contentment by Cyndi Lee, Yoga Journal

3. Overview of the Respiratory System (including client education material)
a. Roles of Diaphragm for breathing, Merck & Co., Inc. (Japanese translated version)
b. What are respiratory muscles and how to stretch, Environmental Restoration and Conservation Agency (in Japanese)
c. Respiratory Rate, Physiopia

4. Stress and Anxiety
a. The Pancha Vayu Model, SequenceWiz.com
b. Collarbone Tapping, Therapeutic Yoga Teacher Training Manual
c. The Impressionable Lungs, Yoga of the Subtle Body by Tias Little
5. Other
a. Joint Freeing Series, Mukunda Stiles
b. +Sun Salutation, Integral Yoga Institute Basic teacher Training Manual
c. Ahimsa, Yamas and Niyamas by Debra Adele
d. Inside the Yoga Sutras by Rev. Jaganath Carrera
e. Loving Kindness Meditation, script inspired by UCLA Health Mindful Awareness Research Center

• Yes

Session Date: 1/4/2024 Time:10:30-12:30 PM Location: Virtual on Zoom

Activities:
1. Measurement of respiration rate
2. Body/Breath scan
3. Client Education – Neti pot
4. Asanas (Part 1) - Joint Freeing Series (Upper body, spine)
a. Neck - Rotation (Look over R/L shoulder), lateral flexion (Ext arm. R ear to R shoulder, look down)
b. Shoulder - Rotation
c. Spine - Lateral flexion (in chair. Interlace fingers), rotation (Sit sideways, inhale arms up, twist)
2. Pranayama (Part 1)
a. Breath Pattern Observation in Savasana (5-10 mins) Hand on lower ribs and upper abdomen
b. Deep Breathing in Savasana (2-3 mins)
c. The Wave. Exhale, bring the knees to the lower abdomen; Inhale, let the feet drop toward the floor, arching the lower back (3-5 breath cycles working towards 10-15)ee.
3. Asanas (Part 2)
a. Bridge/Shoulderstand variation w/chair
b. Feet on the seat
c. Head Rolls
d. Savasana
4. Pranayama (Part 2)
a. Pursed-lip Breathing. Exhalation w/abs squeeze (in Savasana) 2-3 mins
5. Restorative yoga - Supported Fish (w/blanket)
6. Measurement of respiration rate in a supine position
Meditation - Breath as Mantra Meditation
7. Discussions - Home Practice schedule, Q&A

Weekly assignments, resources, and handouts for the sessions were shared with KKO in a GoogleDoc

1. Asanas　
1. Joint Freeing Series by Yoga Therapy Center. No. 13-21 x3 sets
2. Bridge to Shoulderstand w/chair 30 sec x2
2. Pranayamas in supine position
1. Breath Pattern Observation in Savasana (1-2 mins)
2. The Wave x5 sets
3. Pursed-lip Breathing x10 sets
3. Meditation - Breath as Mantra Meditation (Audio file)
4. Measure respiration rate after the daily practice and record it on the Home Practice Tracking Sheet. Also note, any changes you noticed

KKO reported a busy holiday season, hosting a large extended family. While standing for an extended period in the kitchen, she was able to maintain stamina. Crossing a street hurriedly, climbing stairs, or changing her body position quickly caused shortness of breath (Self-reported breathing difficulty as bad as 4 or 5 out of 5). These events held her back from going out with the grandchildren. She feels she now has a better understanding of her physical limitations.

It is observable that KKO started to pay closer attention to her breathing patterns and what affects her respiratory functions, which indicates her improved interoceptive awareness. She recounted her breath became erratic when arguing with her husband (it was over his resistance to wearing a hearing aid). She understands the need to keep herself from getting upset to counter shortness of breath. She also used Alternate Nostril Breathing to pacify coughing at night and pleasantly discovered its positive effect. Built on her mastery of the basic technique, she was instructed for extended exhalation.

The short- and long-term goals were discussed. She liked them and stated she would comply with home practice for 20 minutes daily in the late morning. Neti pot kriya was suggested for congestion, to which she has not responded positively despite having one at home.

Pranayamas were performed without any difficulties. She has kept focused and attentive. She reported mild cramping in the calf during the bridge/shoulderstand variation. Instructed initially to hold the pose longer in the reference book, we shortened it to 30 seconds to gradually build up.

The respiration rate improved significantly with the interventions: 26 sets per minute at the beginning of the session, whereas 15 per minute at the end of the session.

More warm-ups before bringing her up to the bridge/shoulderstand variation could have avoided the cramping. The suggestion was made to warm up the body with the Cat-Cow-Downward Facing Dog sequence to stretch the posterior structure when she practices at home.

Measuring the respiration rate before and after the session successfully quantified the effects of the interventions. On average, healthy people breathe 12 times per minute. It could be a temporary result, but it gave her confidence and a sense of self-efficacy that it is possible to breathe fully and more efficiently with awareness. I encouraged her to keep a daily record in her home practice chart.

A full-body warm-up will be given before practicing the bridge/shoulderstand variation. Two rounds of sun salutation, with which she is already familiar, will be added to the activity plan. She will be introduced to the concept of Vayus, as the healthy flow of prana is vital to the health of both gross and subtle layers/Koshas.

• Yes

Session Date: 1/9/2024 Time:10:30-12:30 PM Location: Virtual on Zoom

Activities:
1. Centering using Breath Pattern Observation
2. Check-in
3. Client Education
a. Respiration and autonomic nervous system
b. How yogic breathing can stimulate the parasympathetic nervous system
c. Panch Vayus overview and presentation of What are Vayus?
d. Prana Vayu
4. Pranayama (Part 1)
a. Alternate Nostril Breathing with extended exhalation 1:2
b. Prana Breath
5. Asanas
1) Seated in a chair
a. Spinal lateral flexion (Crescent moon)
b. Spinal rotation (Sit sideways, inhale arms up, twist)
c. Spinal Flexion (Seated Crunch)
2) Standing:
a. Tadasana > Spinal extension (Collarbone and Upper Chest Opening using a strap)
b. Warm-up: Sun Salutation x2
3) Mat practice
a. Bridge/Shoulderstand Variation (review)
b. + The Wave (review)
c. Savasana
6. Restorative yoga with mantra meditation (10 mins)
a. Reclining Butterfly
b. Acoustic Mantra Meditation (Japanese Version) (5 mins)
7. Pranayama (Part 2) – Prana Breath (review)
8. Meditation with Prana Mudra

1. Asanas　
a. Joint Freeing Series by Yoga Therapy Center. No. 13-21, x3 sets
b. Collarbone and Upper Chest Opening Stretch using a strap. 5 breaths x2
c. Sun Salutation for warm-up. x2
d. Bridge to Shoulderstand variation w/chair. 1 min. x2
2. Pranayamas
a. Prana Breath x10
b. Alternate Nostril Breathing with extended exhalation 1:2. 2-3 mins
3. Tapping
4. Meditation
a. Acoustic Mantra Meditation (Audio File/7 mins)
b. Meditation with Prana Mudra. 2-3 mins

Resources and Handouts:
1. What are Vayus? (Presentation material)
2. What are Mudras? Article on Yoga Journal (Japanese)

KKO was fully compliant with the daily home practice. She reported that completing the regimen took 15-17 minutes daily and felt she could have taken on more. She requested we review “The Wave” movements, so we did. She noticed less congestion in the chest immediately after practicing the Bridge to Shoulderstand variation. However, it didn’t alleviate the congestion in the evening. We will double the pose duration to see if there are any changes (30 seconds to one minute). With ample warm-up, cramps didn’t come back during the Bridge to Shoulderstand variation during the session.

She kept a record of her respiration rate for the last five days. The data corroborated with the improvement seen at the previous session: it normally starts at 24-25 times/min, then slows down to 13-15 when she ends the practice routine. She reported that she was not as quickly exhausted in the later afternoon when she used to take a nap.

Alternate Nostril Breathing with extended exhalation (1:2) was performed without difficulty. She noted that this practice “makes sense” to her as her doctor also emphasizes longer exhalation when using a nebulizer. She enjoyed tapping and appeared to have experienced profound calmness from this contemplative practice.

KKO has given Acoustic Mantra Meditation, where a personal mantra will be the focal point for meditation. This was to familiarize her with the experience of meditation for deeper healing in more subtle koshas. An audio script was prepared for her daily home practice to see if she would notice changes.

Her response to the introduction to Vayu and Mudra practice was neutral. She does not appear to have resistance to subtle practices; however, she was not expressive enough to tell if she enjoyed them. On the other hand, tapping seemed to be a more familiar concept to her due to her cultural background, in which Chinese medicine is widely practiced.

Ahimsa will be introduced. Practice non-harming and self-compassion via asanas and Loving Kindness Meditation.

• Yes

Session Date: 1/19/2024 Time: 9:00-10:45 AM Location: Virtual on Zoom

Activities:
1. Centering using Breath Pattern Observation
2. Check-in. Self-assessment on progress
3. Introduction to Sutras
a. Yamas & Niyamas – Ahimsa
b. Pratipaksa bhavana
4. Pranayama (Part 1) (in a seated position)
a. 1:2 Breathing
b. 1:2 Breathing w/retention after exhalation
5. Asanas
a. Neck - Rotation (Look over R/L shoulder), lateral flexion (Ext arm. R ear to R shoulder, look down)
b. Shoulder - Rotation
c. Sun Salutation x2, as warm-up for Bridge Pose
d. Bananasana (Lateral spinal flexion in the supine position)
e. Rollie Polly (Spinal flexion (Hug the knees, lift the head)
f. Bridge/Shoulderstand Variation
6. Restorative yoga - Resting Half Moon
7. Loving Kindness Meditation
8. Pranayama (Part 2) (in a seated position)
a. Kapalabhati
b. + Alt. nostril breathing w/extended exhalation w/pratipaksa bhavana/Bhakti
9. Wrap-up. Plans for the future practice. Exit feedback and Q&A

1. Create a home practice routine based on the Weekly Home Practice shared document
2. Order the translated version of Science of Yoga (Ann Swanson) and Yamas and Niyamas (Deborah Adele) via Amazon
3. Continue to attend weekly hatha class

KKO reported that he amount of the home practice assignment was overwhelming last week. As changing her body position—sitting to lying down, and vice versa—triggered coughs, she sometimes practiced nothing more than joint-freeing exercises and pranayama. She reported the transition from Downward-Facing Dog to Low Cobra was challenging in Sun Salutation. Weakness in the upper arms and core is suspected. Coming into sphinx has been suggested as an alternate, which was demonstrated during the session. She was able to perform the modified transition and felt it was more accessible.

Pursed-lip Breathing was modified as dryness inside the mouth was uncomfortable to her. New instruction was given to inhale instead through the nose (“as if you are smelling a rose”) and exhale through a pursed lip “slowly blowing a candle,” to which she responded positively.

KKO monitored her respiration rate in the past ten days, which continued to show a significant improvement. Although her phlegm accumulation in the chest didn’t change much in the evening, she was happy that she had been doing pranayamas correctly to breathe deeper.

On the occasions she pushed herself too far with Sun Salutation, KKO noticed her energy depleted and worsened fatigue. This was an opportunity to discuss self-care in the spirit of ahimsa. That led to introducing the intention behind Loving Kindness Meditation, which was practiced at the end of the session.

Respiration rate, i.e., the number of breaths per minute, is a vital process for humans, and it is highly regulated to enable cells to produce optimal energy at any given time. Through this case study, it was exciting to see that the comprehensive yoga practice, including asanas that release tightness around the shoulders, back, chest, and abdomen, pranayama, and meditation, successfully substantiated the improvement in her respiration with quantifiable data. My client felt better and more energetic after the home practice when done the right amount, boosting the health of Annamaya and Pranayama Kosha. Another highlight was her gained awareness—of her breathing pattern but also of her physical limitations and how emotions influence her breathing. It suggests improvement in the integrity of Manomaya and Vijnanamaya Kosha via witnessing and mindfulness.

My client did not have unrealistic expectations about significant changes in her pulmonary condition. At the end of the day, she still suffers from shortness of breath and chest congestion. Still, she is equipped with improved self-efficacy and skills for minimizing further suffering by mindfully responding to various life situations. She was equally delighted when she discovered her yoga practice could improve her respiration rate, allow her to breathe more deeply, and optimize her respiration within her limited lung capacity. That experience alone could have given her hope and served as nourishment for Anandamaya Kosha.

Yoga therapy can be a great gift to people living with chronic illnesses who could quickly develop the tendency to identify themselves with the disease. At the exit feedback, KKO stated that the program helped her recognize the unhelpful tendency (samskara or vasana) in her and opened her eyes to the areas for self-exploration beyond her physical limitations. She expressed her renewed interest in yoga as an intact system beyond asanas and pranayamas. She requested that I point to reading material on yamas and niyamas in Japanese, whose basic ideas were discussed briefly at the last session, and then explored how each tenet could be relevant to her life situation. Studying yamas and niyamas will serve her well as a practical guideline as she navigates life and hopefully motivate her to go deeper into yoga philosophies through studying sutras.

The four-week yoga therapy program has concluded. KKO will curate her home practice regimen for continuity, referencing the list of shared documents of Weekly Home Practice. She will respond to the Client Feedback Form to evaluate the program. She will contact me should there be a need for a follow-up session or support in continuing home practice.