New Client Intake Form

First Name

Last Name

Date of Birth

Email Address

Phone Number

What do you hope to gain from your personalized program with Sonya?

Wellbeing Survey

Please fill out the following form to help us understand your physical condition.

Are you CURRENTLY in physical discomfort? If yes, please describe what makes it better, and what makes it worse?

Do you have any physical or health concerns that might impact your participation in class? If yes, please describe:

Yes

PHYSICALLY: On a scale of 1-10, with 1 = stiff and 10 = agile, what number do you most often experience?

Is there a consistent time of day or night that you notice discomfort or pain? If so, please describe.

Yes

Usual Bedtime rituals:

Typical Bedtime:

Typical Waking Time :

What times do you eat?

How much water per day do you drink?

What is your favorite time of day and why?

What is your favorite season and why?

Please list your typical daily activities.

Below please list additional information you’d like to share:

Release Agreement and Waiver of Liability

I, hereby agree that:

1. I am voluntarily participating in Yoga Instruction offered by Sonya Chapnick of Yoga Gently, during which I will receive information and instruction about yoga and health. I recognize that yoga requires physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved.

2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in Yoga Instruction. I warrant that I am aware of any medical condition that I may have, which may affect my participation, and I agree to fully disclose this information to Sonya Chapnick of Yoga Gently.

3. In consideration of being permitted to participate in Yoga Instruction, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I or my property might incur as a result of participation in the program.

4. In further consideration of being permitted to participate in Yoga Instruction, I knowingly, voluntarily and expressly waive any claim I may have against Sonya Chapnick of Yoga Gently for injury or damages that I may sustain as a result of participation in the program.

5. I, my heirs or legal representatives forever release waive, discharge and covenant not to sue Sonya Chapnick of Yoga Gently for any injury or death caused by their negligence or other acts.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

New Client Intake Form

Wellbeing Survey

Release Agreement and Waiver of Liability

Back to Top

<

New Client Intake Form ​

Wellbeing Survey

Release Agreement and Waiver of Liability

Back to Top

New Client Intake Form