CONTACT FORM | Intentions Yoga

New Client Intake Form

First name

Last name

Birthday

Year

Month

Day

Address

Phone

Occupation

Emergency Contact (name & number)

Have you practiced yoga before?

yes

If yes, how often?

Daily activity level 1-10?

Daily stress level 1-10?

What are your personal healing and health goals with respect to our time together?

In your own words, what aspects of yoga and somatic work are you most interested in? (yoga, meditation, somatic experiencing)

What experiences have shaped your life and who you are today? Both positive and negative.

Do you currently have any spiritual wellness practices that help?

Do you have any physical limitations that I should know about? Please explain.

Are you currently taking medications?

yes

If you are taking medications, which ones?

Is there anything else you would like me to know?

By checking this box, you confirm that Yoga and Coaching is not a substitute for medical care and that you are responsible for your own wellbeing. You agree to inform Alecia Iwanchuk of any health conditions and have medical approval if pregnant or post-surgical. You release and waive all claims against Intentions Yoga and Alecia Iwanchuk.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

New Client Intake Form

Let's Stay Connected