Yoga Therapy & Alignment Consultation Form
Free client consultation
Rhiyz- Restorative Holistic Integrated Yoga Zone
Name & Surname *
Email *
Address/Contact details
What are your chief health concerns? *
1 point
Have you ever practiced Yoga & Meditation? *
1 point
Current Concerns and Relevant History, Past Medical History (surgeries, significant illnesses, injuries) Medications and Supplements *
Disclaimer
I understand that yoga therapy includes diverse activities such as, but not limited to, physical activity, breath work, meditation and touch. As is the case of any physical activity, the risk of serious or disabling injury or death is present despite the best efforts of all involved. I further understand that yoga therapy is not a substitute for medical attention, examination, diagnosis or treatment. I understand that before beginning yoga therapy, it is recommended that I consult with my physician to ensure that I am physically and psychologically ready to participate and assume all risks connected with yoga therapy. I agree that if I experience any pain or discomfort – whether physically or emotionally – I will listen to myself and discuss such with my therapists. I will never do anything that causes pain. With a full understanding of the potential risks, I hereby assume the risks of yoga therapy. I affirm that I alone am responsible to decide whether or not to take the suggestions offered by the yoga therapist. I hereby agree to irrevocably waive, release and discharge any claims and/or liabilities for personal injury or damages of any kind that I have now or hereafter may have against Vitality Nutrition and Wellness Centre team members thereof as a result of my choice to participate in yoga therapy.
Client Signature:_______________________ Date:__________________
What are your yoga therapy goals? How much time per day are you willing to commit to a yoga therapy practice? *
Additional notes
Email Rebekahrhiyz@gmail.com or visit www.rhiyz.com for more information or make contact on facebook and instagram
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