Private Yoga Intake Form
Indicates required field
Name and Number
Client Referral / Friend
Publication / Article
Have you practiced yoga before?
How often do you practice yoga?
What styles of yoga do you normally practice?
Asana (physical practice)
Pranayama (breath work)
What do you want to achieve from private classes?
Address health concern
Lifestyle and Health
Please review this list and select those conditions that have affected your health either recently or in the past.
Diabetes type 1 or 2
High/low blood pressure
Heart condition/chest pain
Numbness, tingling anywhere
What is your current level of fitness?
How would you rate your level of stress?
1 is lowest, 10 is highest
If any of the information on this form needs further detail, or if there is anything else to share, please do so:
Please read the following information and accept below.
I am delighted to welcome you as a yoga student at Yogivibesaruba. The following information will help you get the most out of your yoga classes and clarify the instructor/student relationship.
I believe that Yoga is more than physical exercise. It is a transformative practice that integrates body, mind and emotional tensions to arrive at deeper levels of relaxation and awareness. As with any physical activity there is a risk of injury associated with yoga.
The decision to perform any exercise is down to the individual, and Yogivibesaruba cannot accept responsibility for problems during or outside a class. The participant agrees to take on full responsibility for their actions within the class and shall work within their own limits. If students have any inquiries or health concerns it is their responsibility to notify the instructor so that she is aware of your limits. If you are in doubt as to your fitness, please consult your physician beforehand.
Yogivibesaruba shall not be held liable for any injury, loss or damage to property and/or persons sustained during or as a result of participation in this class. I agree to listen to my body and monitor myself during every class session. I agree to the Terms and Conditions
as stipulated by Yogivibesaruba, including the cancellation policy.
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