Private Yoga General Information

First name

Last name

Phone

Birthday

Month

Day

Year

Address

Your Yoga Practice

Please describe an average weekly practice schedule (how many days, in-studio/home, meditation/mindfulness, etc).

What other types of movement do you currently incorporate into your weekly schedule?

How long have you been practicing yoga?

What are the things that you love about the practice?

Is there an aspect of the practice that you struggle with or that you want to work on?

What are your goals for private yoga instruction?

Do you have any current or previous injuries/restrictions?

Do you have any medical conditions that affect your practice?

Do you have yoga equipment at your home? (Mat, blocks, strap, bolster, blanket)

Is there anything else you'd like to share?

Informed Consent

I confirm that I am responsible for my own physical and mental well-being. I will communicate with my instructor about any discomfort or pain and I will seek medical advice when appropriate.

Signature

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