PRIVATE YOGA INTAKE FORM

    Your Name (required)

    Age (required)

    Home Address (required)

    Your Email (required)

    Your Phone number

    Your Occupation

    Emergency Contact (required)

    Referred By (required)

    Client referral/Friend
    ecourse or program
    Flyer
    Search engine

    Yoga Experience

    Have you ever practiced yoga before? (required)

    YesNo

    If yes, how often do you practice yoga?

    DailyWeeklyMonthly

    What styles of yoga do you normally practice?

    Ashtanga
    Vinyasa Flow
    Restorative
    Yin
    Iyengar
    Rocket
    Power
    Bikram/Hot
    Hatha/Gentle

    What do you want to achieve from private yoga classes? (required)

    Strength training
    Flexibility
    Balance
    Stress relief
    Address health concern
    Alternative therapy
    Improve fitness
    Weight management
    Enhance well-being
    Injury rehabilitation
    Positive reinforcement
    Other reason

    Yoga interests (required)

    Asana (Physical practice)
    Pranayama (breath work)
    Meditation
    Yoga philosophy
    Other interest

    Lifestyle and Health

    What is your current level of fitness? (required)

    Very inactive
    Fairly inactive
    Average
    Fairly active
    Very active

    On a scale of 1-10, (1 is lowest, 10 is highest) how would you rate your level of stress? (required)

    12345678910

    Please review this list and select those conditions that have affected your health either recently or in the past.

    Broken/dislocated bones
    Diabetes type 1 or 2
    Pregnancy
    Muscle strain/sprain
    High/low blood pressure
    Surgery
    Arthritis, bursitis
    Insomnia
    Seizures
    Disc problems
    Anxiety/depression
    Stroke
    Scoliosis
    Back problems
    Asthma/ short breath
    Cancer
    Osteoporosis
    Heart condition/Chest pain
    Numbness, tingling anywhere
    Auto-immune condition (AIDS, fibromyalgia, chronic fatigue, lupus, etc)
    Other

    If any of the information on this form needs further detail, or if there is anything else to share, please do so:

    Please read the following information and accept below.

    I am delighted to welcome you as a yoga student at The Yoga Transformative. The following information will help you get the most out of your yoga classes and clarify the instructor/student relationship.

    I believe that Yoga is more than physical exercise. It is a transformative practice that integrates body, mind and emotional tensions to arrive at deeper levels of relaxation and awareness. As with any physical activity there is a risk of injury associated with yoga.

    The decision to perform any exercise is down to the individual, and the instructor (Tali) cannot accept responsibility for problems during or outside a class. The participant agrees to take on full responsibility for their actions within the class and shall work within their own limits. If students have any inquiries or health concerns it is their responsibility to notify Tali so that she is aware of your limits. If you are in doubt as to your fitness, please consult your physician beforehand.

    Tali shall not be held liable for any injury, loss or damage to property and/or persons sustained during or as a result of participation in this class. I agree to listen to my body and monitor myself during every class session. I agree to the Terms and Conditions as stipulated by Tali, including the cancellation policy.

    I accept the statementI do not accept the statement