Make it stand out.

Yoga Intake Form

Name

First Name

Last Name

Phone

(###)

###

####

Pronouns

She/Her/Hers

He/Him/His

They/Them/Their

I would rather not say

What goals would you like to work on during your Yoga practice?

Do you have any physical ailments that are challenging for you?

What experience do you have with Yoga?

Is there anything that would prevent you from doing your Yoga practice? (examples - time, energy, availability, pain, people, space)?

Are you an adult or a minor?

I am an adult over 18 years.

I am the caretaker or guardian of the student.

Electronic Signature

By digitally signing below, you are authorizing Laura Wheeler, LMT, RYT-500, ICHC to provide Yoga instruction to you. You are also releasing Laura Wheeler, LMT, RYT-500, ICHC of any liability financial or else wise should and symptoms unknown or previously known be aggravated or inflamed. Yoga is intended to be beneficial to the body ,mind and spirit. Although it is uncommon, there may be some brief discomfort, your Yoga session should not be painful. By signing this form you state that you will let Laura Wheeler, LMT, RYT-500, ICHC know if any aspect of the Yoga causes discomfort or pain so that you may be properly adjusted, advised to stop pr guided according to your needs. You also state by signing this form that you have informed Laura Wheeler, LMT, RYT-500, ICHC of any illnesses, diseases or conditions that would make Yoga inappropriate for your health to your best knowledge. Please sign and date below.

Make it stand out.

Yoga Intake Form

You are grace. ♡