Private Intake Form

Today’s Date: ___/___/___

Name:________________________________________________________________________
___________ DOB: ___/___/___ Age: _____ Height: _____ Weight: _____ Address:
_________________________________________ City/State/ZIP:
_______________________________________ Phone (Home)___________________
(Work)___________________ (Cell)___________________ E-mail:
_________________________________________________________________________
Current Occupation:
______________________________________________________________
Emergency Contact:____________________________________(Phone)___________________

Current exercise program:

______________________________________________________________________________
______________________________________________________________________________
______________________

Experience in yoga, barre, and/or meditation:

____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________
What do you wish to receive from your session?
____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________________________________
Is there anything else you’d like me to know before we start our work?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________________________

Private Yoga Intake Form Please fill out the following form.
Use the back side of the form if more room is needed.
____DID ____Eating disorder ____Emphysema or other breathing problem ____Fibromyalgia
____Fatigue ____Fused vertebrae ____Grief/Bereavement ____Heart Condition ____Hernia
____High blood pressure: Type ____ ____Hepatitis: Type ____ ____History of Physical Abuse
____History of Sexual Abuse ____Insomnia ____Low blood pressure ____Menopause
____Multiple sclerosis ____Osteoporosis ____Panic Attacks ____
Pregnancy: How many months? ____ ____
Other _________________________
 Private Intake Form

Please list below any prescription or non-prescription medication you are taking:
______________________________________________________________________________
_____________________________
______________________________________________________________________________
_____________________________ Please list any history of surgeries, major illnesses, chronic
conditions, accidents, injuries or anything that might be relevant to doing our session which were
not listed on the previous page:
______________________________________________________________________________
______________________________________________________________________________
_______________________________________________
Please check any condition that applies to you: ____Addiction Recovery
____Anger____Anxiety ____Arthritis ____Asthma ____Bulging or herniated disc ____Chronic
Fatigue Syndrome ____Chronic Pain ____Contact lenses ____Degenerative disc disease
____Depression

Scheduling

Session take place at the same time/day each week as consistently as possible.
Clients or Teacher will use Acuity Scheduling app to schedule or cancel each session.

Cancellation

24 hours notice must be given for cancellation without full charge. If less than 24 hours notice is
given for cancellation, the client will be billed for full session price, or session will be counted as
used from the package. When possible, teacher will offer a “make up” session during the same
week of missed session if more than 24 hours notice is given. If teacher is not available for a
“make up” session during the same week as the cancellation, an additional session may be
scheduled for a future date. If the teacher cancels due to illness or emergency, the missed session
will be credited in full toward a future session.

Expiry

Packages must be used with a six month period. Unused sessions will expire if not used within
six months.

I ________________________________________ have read and understand the payment,

scheduling, and cancellation policies

Client Signature__________________________________________
 Private Intake Form
Liability Waiver

I, _________________________ (name) understand that yoga includes physical

movements as well as an opportunity for relaxation, stress re-education and relief
of muscular tension. As is the case with any physical activity, the risk of injury,
even serious or disabling, is always present and cannot be entirely eliminated. If I
experience any pain or discomfort, I will listen to my body, discontinue the
activity, and ask for support from the instructor. I assume full responsibility for any
and all damages, which may incur through participation.

I understand that yoga or barre are not a substitute for medical attention,
examination, diagnosis or treatment and that yoga or barre are not recommended
and are not safe under certain medical conditions. By signing, I affirm that I am in
the physical condition to participate in such a program. I understand that I am
participating in yoga or barre at my own risk. In addition, I will make the instructor
aware of any medical conditions or physical limitations before class. If I am
pregnant, become pregnant or I am postnatal or post-surgical, my signature verifies
that I have my physician's approval to participate. I also affirm that I alone am
responsible to decide whether to practice yoga or barre and participation is at my
own risk. I hereby agree to irrevocably release and waive any claims that I have
now or may have here after against Kelli Durrance and Dynamic Yoga and Barre
LLC

I have read and fully understand and agree to the above terms of this Liability
Waiver Agreement. I am signing this agreement voluntarily and recognize that my
signature serves as complete and unconditional release of all liability to the
greatest extent allowed by law in the State of Florida

Signature: ______________________________________________

Date: ________________