Private Lesson Intake Form

Provide Student Information
Provide information for yourself, or for the Student if completing this form on behalf of someone else. Please provide as much information as possible. * = required.
Name *
E.g., she/her/hers, they/them/theirs, he/him/his
Date of Birth *
Date of Birth
Phone *
Phone *
General Health Information
Please write N/A if not applicable.
(E.g., dressing, bathing, cooking, cleaning, walking)
Have you received physical therapy in the past for an injury? *
Are you currently pregnant? *
Please discuss with the Teacher any medical condition that might affect your participating in the Activities. All information you provide to the Teacher in this input form or otherwise will be held strictly confidential.
Your Yoga Practice
How often do you practice? Which postures do you practice during a typical session? Do you meditate? Do you practice pranayama (breathing exercises)?
Can we connect on social media?
If yes, please provide details.
I agree that the information provided above is honest and correct *
Type your name here, either as the Student, or as the Parent/Legal Guardian/Proxy if you are completing this form on behalf of someone else. If you are completing this form for someone else, please also describe your relationship (e.g., parent, carer, etc.)
Date *