Yoga Intake Form
Little Champs Therapy & Yoga
Patient Information
Name
First Name
Last Name
Diagnoses
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
General Information:
How would you prefer sessions?
In-person
Teletherapy
Both
Does your child have any previous experience with yoga? If so, how many years and where?
If your child has done yoga, what is their favorite pose?
Current services patient is being treated for:
Does child have any physical limitations? If so please explain:
Contraindications (medical conditions?)
Physical disabilities?
Injuries?
How does your child engage with other kids in the room?
Does your child present any behavior(s) that might impact ability to engage in yoga therapy? If so please explain:
Goals for child?
Disclaimer: the yoga will be taught with breath work (controlled breathing to help destress and regulate the mind and body)? If you want to opt out please mention why
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Photo/Video Consent
I give permission for myself/my child to be photographed or recorded during yoga therapy sessions for the purposes of documentation, educational materials, marketing, or social media related to the program. I understand that names will not be used without additional consent.
Yes, I give permission
No, I do not give permission
Signature
Date
-
Month
-
Day
Year
Date
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Package Pricing:
Please review and select one of the available package options below:
Yoga Packages
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( X )
10 sessions
$
650.00
Quantity
1
2
3
4
5
6
7
8
9
10
20 sessions
$
1,250.00
Quantity
1
2
3
4
5
6
7
8
9
10
30 sessions
$
1,800.00
Quantity
1
2
3
4
5
6
7
8
9
10
Yoga For Change Group Class
Must give 48 hours notice for cancelations
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Submit
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
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