1:1 Sessions & Programs Application Form
with Jaylyn Bernachi | Innerswim | jaylyn@innerswim.com
Any information shared is completely confidential and will only be viewed by Jaylyn. The email & phone number you provide will be used for direct contact purposes only.
Full Name
*
First Name
Last Name
Age
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
How do you prefer to be contacted?
By email
By phone
Would you like to be added to my email list?
Sure
No thanks
Which service are you most interested in?
*
Yoga and Meditation
Wisdom of the Cycle Mentorship
Holistic Fertility Yoga
Pelvic Care
Energy Medicine
If you selected 'Yoga and Meditation' above, please specify:
Yin Yoga
Yoga Nidra (Yogic Sleep)
Hatha Yoga
Yoga Philosophy
Meditation
Unsure
Why does a 1:1 session or program appeal to you?
*
Do you have any experience or history with these practices/services? If so, please briefly explain.
What do you hope to gain from our time together?
*
Will our session(s) be taking place virtually or in-person?
*
Virtually
In-Person (I am local/travelling)
Both
Not sure
Please fill out a couple date/time options that could work for you to meet.
*
Is there anything else you would like to share?
Thank you! I will be reaching out shortly.
Love, Jaylyn
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