INITIAL CLIENT FORM

INITIAL CLIENT FORM

SHAVA YOGA Private consultation with Phillida Bartik or Jesse alexander.
Name

First NameLast Name
Phone Number

Country CodePhone Number
Date of Birth

DayMonthYear
Date
Email
example@example.com
Emergency Contact

NameContact Number
How long/often have you been practicing yoga?
What style(s) of yoga are you interested in?

MeditationYoga NidraRestorative YogaVinyasa YogaLunar Hatha PracticeSolar Hatha PracticeYin YogaPranayamaMantraOther
Are you currently taking any medications?

YesNo
If yes, then please indicate the medication name and the purpose below:
Do you have any health conditions or physical limitations that you would like to share?

YesNo
If yes, then please share them below:
What is your intention for our session(s)?

Postural/alignment supportGreater energetic understanding and application of yogaGreater philosophical understanding and application of yogaPain/injury resolutionYoga practice adaptation due to limitation or change in bodyRelaxation/ balancing nervous systemAyurveda informed yoga approach to daily life to complement current lifestyleDevelop a daily practiceEmotional stability/supportSpiritual inquiryIntroduction to yogaStabalising sleep patternsOther
Are there any additional comments?
What consultation do you request?

Private consultationPrivate consultation for people with disabilityGroup workshop inquiry
Who do you request to have your consultation with?

Phillida BartikJesse AlexanderEither
How often do you require our session(s)?

One off sessionOngoing sessionsAs neededOther
Desired location for session(s)?

Modern Movement Studio (Incurs additional $20 fee for studio hire)Your homeOnline (Zoom)Other
AGREEMENT:

I understand that all information I entered in this form will be considered strictly confidential. The data gathered from this form will only be used as a basis to discern the needs and intentions of our session(s) together.

Yoga is not a substitute for medical attention, examination, diagnosis, or treatment. These forms of exercise are not recommended and are not safe under certain medical conditions. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any sessions with Phillida or Jesse. I represent and warrant that I am physically fit and I have no medical condition which would prevent my participation. I knowingly and voluntarily waive any claim I may have against Phillida Bartik, Jesse Alexander and/or Shava Yoga.

Thank you.

Yours in health,
Shava Yoga
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How did you find out about our services?

Social MediaYouTube VideoSearch EngineWord of mouthModern Movement StudioOther
Would you like to subscribe to Shava Yoga for upcoming information on retreats, workshops, courses and more?

YesNo
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