Private Yoga Therapy Intake Form
Greetings Beautiful! Please fill out the form below so we have the best information to create your custom plan of care. All answers are safe and will not be shared.
PERSONAL INFORMATION
Please enter your info here so we can stay in contact with you.
Name *
Your answer
Address *
Your answer
Email *
Your answer
Best number to reach you? *
Your answer
Birthday
Your answer
Current Occupation
Your answer
Emergency Contact Name *
enter the name and number of the person you'd like us to contact in an emergency
Your answer
Emergency Contact Number *
Your answer
YOUR MOTIVATIONS
take a moment and breathe before answering these questions
What brings you immense joy? *
Your answer
What would you like to eliminate from your calendar? *
Your answer
What would you like to achieve out of our sessions together? *
Your answer
What physical, mental or emotional benefits are you looking for? *
check all that apply
Required
LIFESTYLE & FITNESS
How would you rate your current level of activity *
Please list any physical activities you are currently performing:
Your answer
Have you practiced yoga before? *
Give an estimate of your last yoga class/practice *
The practice could have been at a studio, event or in your home
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On a 1 (low) to 10 (high) scale, what is your current level of Energy? *
Required
On a 1 (low) to 10 (high) scale, what is your current level of Stress? *
PHYSICAL HISTORY
Please review this list and check those conditions that have affected your health either recently or in the past.
*
Required
When would you like to start the Yoga sessions? *
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Time
:
If any of the information on this form needs to be detailed or if there is anything you'd like to share, please do so: *
Your answer
I agree to give at least 24 hours notice for any cancellations or modifications to my scheduled appointment, if at all possible. I can call, text, email, or all of the above to notify Nazaahah Amin of any schedule changes. INITIAL HERE: *
Your answer
PLEASE READ THE FOLLOWING INFORMATION AND SIGN BELOW: I am thrilled to have you as a yoga client at Ama Wellness. The following information will help you get the most out of your yoga therapy session and clarify our instructor/student relationship. Yoga Therapy is a transformative practice that integrates body, mind and spirit to arrive at deeper levels of relaxation and awareness. By choosing to participate in yoga classes, you voluntarily assume a certain risk of injury. By attending these sessions, I affirm that I am solely responsible for my health and well-being, as well as my decision to practice yoga, a program of physical exercise. I agree to inform my yoga instructor of any activities or movements, which I feel could cause injury to myself. Ama Wellness and Nazaahah Amin shall not be held liable for any injury sustained during or as a result of participation in these sessions. I agree to listen to the cues my body gives and monitor myself during every class session. I agree to give at least a 24 hour notice of cancellation to the instructor. If less than 24 hours given I will be charged the full amount of the session. SIGNATURE BELOW: *
Your answer
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