It is important to conduct a thorough, standardized, well-documented initial client intake and assessment to develop a personalized, well-guided, effective client care plan. This process lays the foundation for providing an evidence informed practice co-created with the client by integrating knowledge of the best evidence available.

Conduct a thorough, well-documented client intake assessment using a standardized IYTH intake form, SOAP notes, body and breath assessments, and motivational interviewing. Support summary assessment with relevant research.

Female, age 62, married, retired Catholic elementary school financial administrator. Lives with her husband who is semi-retired from law enforcement. One adult, married daughter with a toddler. Caregiver to her grandson. Cares for her nonagenarian parents. Residence: Eastern, PA. Personal history of anxiety, family history of breast cancer. Recovering from tennis elbow in both elbows resulting from physical demands of caring for her grandson for two years. Walks for exercise.

The plan was to provide the intake form with the client, receive her responses, then meet over Zoom, using motivational interviewing techniques to discuss and add more information as we talked. Taking this information SOAP notes and a summary of the intake, physical and breath assessments would be written. This summary would be shared with the client, along with some practices to facilitate meeting her primary wellness goal.

Hatha Restorative yoga.

Raja Sutra 1.2 The restraint of the modifications of the mind-stuff is yoga., Sutra 1.14 Practice becomes firmly grounded when well attended to for a long time, without break, and with enthusiasm, 2.16 Pain that has not yet come is avoidable., Sutras 2:49 to 2:53, Pranayama; Ishwara Pranidhana.

Bhakti Client’s stated life purpose: “To help our fellow man.” The client is religious, spiritual and prayerful with a loving devotion to God.

Japa The client recites the Rosary daily.

*** Please see uploaded document with relevant yoga and anxiety supporting research and background information. ***

The client presented eager, nervous, unsettled, and fatigued with dark circles under her eyes.

We had two Zoom meetings. We discussed her intake responses, adding information, and conducted physical and breath assessments. I learned that the client’s father has anxiety. She grew up in an anxious household. Her life purpose, “To help our fellow man.” helped me understand why she now cares for three generations of her family: her grandson, her daughter, and her parents.

During the second meeting, the client realized she could indeed find time for self-care each day. We discussed how being consistent in this regard would teach her nervous system a “new normal” from which to operate, creating more calm within.

She was excited to share the joint freeing series with her mother, and the 5 sense awareness with her grandson. Modeling self-care for her daughter was motivating.

Focus on consistency. Affirm to herself the self-care she practices. Weave in extended exhale into her daily restorative yoga practice, keeping the total time for the practice the same. Even interweave extended exhale, into her day such as when cooking or watching TV. Using the Ann Swanson joint freeing series YouTube videos, and five sense awareness practice, make time each day for self-care.

Take time weekly for longer self-care, building upon the monthly massage she already schedules for herself. Find self-care that she really enjoys, so she looks forward to it and will carve out time for it.

Share the practices with her family members as is age appropriate in support of her life’s purpose.

*** Please see uploaded document for more information. ***

Yes, the initial plan was executed as intended and the goal was achieved. It felt incomplete and unfulfilling to end our meetings with the summary assessment, without discussing ideas to address the client’s goals and providing some techniques to facilitate change. Given what the client and I had discussed, after completing the summary assessment, I put together a starter care plan, with some mutually agreed upon techniques and ideas for the client use on a daily and weekly basis. We discussed these practices and her comfort level in being able to remain consistent in her efforts.

*** Please see uploaded document for more detailed information. ***

The process was truncated. Had it not been a TCA, I would have created a complete care plan, shared it with the client, and adjusted it in response to the client’s feedback. I would have scheduled a follow-up meeting to check-in and see how her self-care practices were going, tweaking as appropriate and possibly adding some new practices.

To the extent possible:
• Be prepared for the unexpected at any moment.
• Be fully present for the client.
• Be curious and inquisitive while still holding space for attentive, affirming listening.
• Remember and keep practicing the techniques of motivational interviewing.
• Address the client’s area of focus and goals specifically.
• Try not to make assumptions.
• It is super important for me to keep up my own meditation and sadhana practice so I am better able to do all of the above, staying in-touch with my own inner guide and my own inner wisdom.

Client interactions were easeful. She shared without hesitation and was very willing to make change, knowing this would benefit her family.

The client came to see the multigenerational aspect of the anxiety she experiences. Anxiety became a shared condition partially passed down to her. She could see how her self-care and sharing stress reduction techniques with her daughter and grandson may shift this inherited pattern.

Realizing that one piece of information can tie together many aspects of a person’s outlook, informing assessment and care plan was significant for me. "To help our fellow man," the client's life's purpose, was a key piece of information. Knowing this I understood what motivates and drives her, even to the point of overdrive and exhaustion. I was able to link self-care with caring for her family members, giving space for her to let go of some guilt around not doing.

I believe an established relationship of trust with the client allowed her to speak about her life's purpose freely and openly. Forms are a starting point. It is the interpersonal connection in a safe and supportive space where the true communication happens.