Private Client Intake

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Expected Due Date or Baby Birthdate

MM

DD

YYYY

Rate Your Stress Levels

1 - Low Stress

2 - Low to Moderate Stress

3 - Moderate Stress

4 - Moderate to High Stress

5 - High Stress

What are your goals/expectations for your yoga practice? What benefits are you looking for? *

Fitness

Increase Flexiblity

Injury rehabilitation

Lifestyle balance

Stress management

Other

Policy Acknowledgment *

By checking the boxes, you acknowledge you have read and understand Private Client Policies and Waiver.

I have read and understand Private Client Policies.

I have read and understand the Client Waiver.

Current Date *

MM

DD

YYYY