Yoga Therapy / Private Yoga Sessions

Yoga Therapy / Private Yoga Session Client Intake Form & Agreement

Yoga Therapy and Private Yoga Sessions apply yogic principles and practices, to help you to optimise your holistic health and wellbeing, to achieve your health goals and to thrive in your life. We use yoga postures, breathing exercises, meditation and the application of yogic philosophy and lifestyle approaches to help you to integrate mind, body and spirit. The information you provide in this form allows us to assess your health, wellbeing and therapeutic needs, as well as to clarify the terms and conditions of your sessions/program. Please take a few quiet moments to consider the questions and be as honest and complete as you can in your responses - THANK YOU!

Name:(Required)

Email Address:(Required)

Phone:(Required)

Age and Date of Birth: DD/MM/YYYY(Required)

Religion or Cultural Identity:

1. What are your reasons and motivation for seeking Yoga Therapy or one-on-one yoga support? Do you have a goal for our time together?(Required)

2. Do you have any recent experience with yoga, meditation or stress management techniques? If so, please describe when and what you practise/have practised and how often.(Required)

3. List your current and previous health conditions. Please include any medical diagnoses, surgeries, accidents, injuries etc(Required)

4. List any current medications, including supplements, that you have been prescribed or are taking.(Required)

5. Who else are you currently seeing for your medical/health concerns or support? How often do you see them?(Required)

6. Describe any area(s) of discomfort or pain in your body? Try to describe the location and level of pain/discomfort using a scale of 1 to 10, 10 being the highest.(Required)

7. What current life challenges are you facing? What do you think is getting in your way of making the changes you want in your life?(Required)

8. Describe your sleep habits:(Required)

Regular, good sleep of 6-8 hrs per night. Wake-up feeling refreshed most days.

Irregular, sleep quality is erratic, less than 4-6 hrs per night. Wake-up feeling groggy or difficult to get out of bed.

Poor, insomnia, sleep quality is minimal. Often need to nap during the day.

9. Describe your overall energy level. Does it fluctuate or stay consistent? When are you most energised, least energised?(Required)

10. What are your perceived stress levels - low, moderate or high?(Required)

11. What work do you do? How many hours do you work per day/week? Roughly how many hours do you spend sitting/walking/driving/lifting etc? How would you describe your work-life balance?(Required)

12. Do you experience anxiety, sadness or depression? Are there places in your body where these feelings tend to dwell when they come up?(Required)

13. What aspects of life give you the most joy and pleasure? How often do you engage in pleasurable activities?(Required)

14. How much time (each day and week) can you devote to your health with your own personal yoga practice? And, are you prepared to 'do what it takes'? Please be honest!(Required)

15. If you could change one thing about yourself, what would that be?(Required)

Communication & Confidentiality(Required)

Phone calls only

Phone calls and text

Phone calls and emails

Phone calls, text and emails, as needed.

The way we communicate with each other as Yoga Teacher - Client is an important part of our working relationship and the success of your Yoga Therapy program. Some clients choose to use email, texting and/or social media (includes Messenger) as a way of communicating. At Momentum Yoga, we prefer that clients do not use social media (or Messenger) as a form of communication for the purposes of our program because it is not private, and if we receive your communication via social media (or Messenger), we will redirect our conversation to personal email or text, as appropriate. We are able to communicate with you via email, text and voicemail/phone, as you prefer. Any and all information that you share with Momentum Yoga, and the fact that you are participating in Yoga Therapy, will be treated confidentially and your personal details will not be shared with any third party. Please indicate how you would like to communicate.

Session Fee Terms & Conditions(Required)

I understand and accept the Session Fees and Conditions

Fees are payable in-advance of each Yoga Therapy/Private Yoga Session. Each 90 minute session is $160. Each 60 minute session is $100. Please tick the box to indicate your agreement.

Cancellation Terms & Conditions(Required)

I understand and accept the Cancellation Conditions.

Sessions are booked session-by-session or in a block, as required. Sessions may be cancelled and rescheduled with a minimum of 24 hours' notice. Sessions cancelled without 24 hour's notice will incur the normal session fee. Please tick the box to indicate your agreement.

Release & Liability Disclaimer(Required)

I understand and accept the Release & Liability Disclaimer.

I understand that Yoga Therapy and Private Yoga sessions incorporate both cognitive and physical approaches, and that there is an inherent risk when participating in physical activities. I agree to let the Yoga Teacher know of any physical or mental limitations I might have, or any physical activities I do not wish to participate in. I agree to take full responsibility for not exceeding my limits in my practice of yoga and for any injury that I might suffer in the practice of yoga. It is my responsibility to ascertain that there is no medical reason to prevent my participation and consult with a physician prior to and regarding my participating in a Yoga Therapy Program. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. In consideration of Momentum Yoga's offering of Yoga Therapy, I waive any claim that I might have at any time for injury of any sort against Momentum Yoga. I have carefully read the release, fully understand and agree to the above. I hereby release Momentum Yoga from any injuries I may sustain as a result of participating in this program. Please tick the box to indicate your agreement.

THANK YOU for taking the time to complete the questions and your agreement. If you have any questions or concerns, you should contact Momentum Yoga prior to submitting this form. Otherwise, please type your name and the date below, to signify your acceptance of the above terms and conditions.

Yoga Therapy / Private Yoga Sessions

Yoga Therapy / Private Yoga Session Client Intake Form & Agreement

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