Yoga Client Information Form

Yoga Client Information Form

This information will be used to craft sessions to best meet your needs and goals so please provide as much information as possible.
In home and office sessions are available upon request. Small group classes for 2 or more are also available upon request.
I look forward to sharing the practice with you!

All information offered below is private & confidential and will not be shared with anyone.

Name (First & Last) *
Number of people participating in session *
Address (required if interested in home or office sessions)
Zip Code
Preferred Telephone # *
Cell #
Email *

When would you like your session(s) to begin?

Check your main reason for requesting a private session:

If "Other" selected above, please specify

Are there any health issues I need to be aware of?

(check all the boxes that apply and provide detail as needed):

Provide detail as needed for any boxes checked above

During your yoga session, I may make some gentle hands-on adjustments as needed.
Would you like any hands-on adjustments?

Are you pregnant?

If, Yes:
Unfortunately, I am unable to serve women who are pregnant at this time, however, I can recommend prenatal group yoga classes at the Integral Yoga Institute ( that would perfectly meet your needs.

Have you done any yoga before?
If Yes, what type and for how long?
What were the reasons for leaving (if any)?
Do you have your own yoga equipment such as mats, blocks, blankets, and straps?
Please list all that you currently own.

How would you describe the type of class you would like to have?
(Check one)

As an Interfaith Minister and Reiki Practitioner I am able to bring more to your class experience.
Would you like the spirituality of yoga to be a part of your class experience?
Are you open to chanting traditional Sanskrit chants to encourage healing and peacefulness?
Would you like your personal spirituality to be a part of your yoga experience?
If Yes, please describe your beliefs below.
Would you like me to offer Healing Reiki energy while offering hands-on adjustments and/or during deep relaxation?

What would you like to receive from the practice? 
(check as many boxes as you like)

If you chose "Other" above please specify

Are you interested in more than one Private Yoga Session?

To get the most out of your practice, it is recommended to have more than one private session to help you continue to build on your practice and meet your goals. Consider asking about package plans to get the most out of your yoga experience.

Other Comments, Requests, Questions:

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