New Client Intake Form - Private Yoga Instruction
FOR FAMILY OR INDIVIDUAL INSTRUCTION ONLY

Please fill out the following form to help me guide our sessions more effectively with your success in mind. An instructor will get in touch within 72 hours about scheduling.
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Email *
First Name *
Last Name *
Other Participants Name(s) and Age(s) *
Best phone number *
What is your preferred lesson format?
What is your preferred time(s)?
Anything we should know about scheduling lessons with you, including how many lessons you would like, help us match you with an instructor. Discounts are available for multi-lesson packages.
What is your preferred location for lessons?
Please share anything we need to know.
Have you or other participating family members done yoga before? If so, what style, when, experience level?
Profession
What are your goals with private yoga lessons?
What is your motivation for taking yoga? Check all that apply:
Do participants have any health, behavioral, or emotional concerns that may affect yoga practice?
Please note that yoga, while supportive of health, is not a substitute for medical care and no instruction should be considered medical or mental health advice. Participants are responsible for any necessary medical clearance.
Is there anything we else should know about participants that will help us plan yoga lessons? This could include preferences around poses or activities or tips for engaging your children.
Do you have any questions for us or your instructor?
How did you hear about Breathing Space Family Yoga?
Emergency Contact Full Name *
Who should we call in the case of a medical or other emergency?
Emergency Contact Phone Number *
Emergency Contact Relationship to Student *
Email opt-out:
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Breathing Space.