Private Yoga - Initial Client Intake Form

Personal Information:

First name

Last name

Birthday

Month

Day

Year

Email

Phone

Emergency Contact Information:

Name and Relation:

Phone

Email

Health & Wellness Information:

To ensure a safe and supportive experience, please share any relevant health information that may impact your practice. This may include injuries, chronic conditions, surgeries, or other considerations:

Are you currently under the care of a healthcare professional for any condition?

Yes

No

If yes, please provide any relevant details:

Do you have any movement restrictions, pain, or sensitivities I should be aware of?

Yes

No

If yes, please describe:

Yoga & Wellness Background:

Do you currently practice yoga?

Yes

No

If yes, please describe (style, frequency, experience level):

Do you engage in other wellness practices? (e.g., meditation, breathwork, physical therapy, strength training, etc.)

Yes

No

If yes, please list:

Goals for Private Sessions:

What are your primary reasons for seeking private yoga sessions? (Check all that apply)

What specific goals or intentions do you have for your yoga journey?

Acknowledgment and Consent:

I understand that yoga is a holistic practice for well-being and is not a substitute for medical care. I acknowledge that it is my responsibility to listen to my body and inform my instructor of any changes to my health. I consent to participate in yoga sessions, understanding they may include movement, breathwork, and mindfulness practices.

Signature

Signature field is empty.

Date

Month

Day

Year