New Guest Intake Form

The information you provide is confidential and will be housed securely. This form is voluntary; it helps the teacher customize the classes and prepare for modifications.

General Information

Name

Date of Birth

Emergency Contact

Emergency Contact Phone

Yoga Experience/Goals

Have you practiced yoga before? If yes, when was the last time? How often?

Please list any other conditions I should be aware of.

On a scale of 1-10 (1 being the lowest, 10 being the highest) rate your average daily stress level in the past 3 months.

If any of the information of this form needs to be detailed or if there is anything else you would like to share with me before the start of any class, please do so.