Client Intake and Waiver for Zoom sessions |

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Please read each statement and check each box to signify your understanding: *

I understand that therapeutic yoga is provided for pain relief, stress reduction, relief from muscular tension, and improvement of circulation and energy flow.
I understand that the services offered are not a substitute for medical care. I understand that the provider is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
I affirm that I will notify the provider of all known medical conditions and injuries.
By signing this release, I hereby waive and release the therapeutic yoga provider from any and all liability, past, present, and future relating to the therapeutic yoga sessions.

Type your full name to confirm you understand the statements above: *

On an average day, what are your activities? *

What's not feeling right to you (aka "what are your complaints")? *

What's your history of major illnesses, injuries, surgeries? Also provide timeframe of when they occurred if you can. *

If you're having pain, what increases and/or lessens it?

What are your short and/or long terms goals for your health & wellness?

What haven't I asked that you'd like me to know?

Do you have questions for me? I'll either answer them via email or at your first appointment.