• Intake Form

    Movement Services
  • Client Information Questionnaire

  • All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to developing a program that addresses your needs, goals, and interests and is safe and effective.

    • Personal Information  
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    • Medical Information  
    • Please provide 24 hours notice if you need to cancel or reschedule your appointment.

    • Please check all conditions you have encountered throughout your lifetime.

    •  
    • Description of Concerns  
    • Participant Release and Knowledge of Agreement  
    • I, *, wish to participate in the exercise and training program offered by Stephanie Watson Lewis I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I have been examined by a physician of my choice and have obtained his/her approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. If a physician has not examined me, I agree to see a physician within sixty (60) days of the date set forth below to obtain his/her approval for my participation in a fitness program. I agree that Stephanie Watson Lewis shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, at the training studio, outdoors, or at a corporate, commercial, residential or other fitness facility) and I expressly release and discharge Stephanie Watson Lewis from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by the gross negligence or intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators, and assigns.

      I agree not to hold Yoga Heart & Mind LLC/Stephanie Watson Lewis, or any of its affiliates liable for any injury or damages related to my participation in 1-on-1 sessions, in person classes, online classes, workshops, trainings, retreats or other activities.

    • I have read this Release and Terms of Agreement and I understand all of its terms. I sign it voluntarily and with full knowledge of its significance.

    • Clear
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