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Private Mentorship Program Registration Form
Venue: Online & In-Person
Contact us at:
info@lorrainetayloryoga.com
www.lorrainetayloryoga.com
All answers are strictly confidential and will not be shared with anyone else.
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Email
*
Your email
First Name and Last Name
*
Your answer
Phone Number
*
Your answer
Address
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Emergency Contact Name & Phone.
Your answer
Whatsapp Number
Your answer
Facebook Profile
This is optional but a good way for us to share group information so highly recommended
Your answer
What style(s) of Yoga do you practice regularly?
Your answer
Are you a yoga teacher?
Yes
No
Clear selection
If you're an active yoga teacher, what classes do you teach and what kind of community do you serve?
Community Classes
Studio classes
Yoga Retreats
Yoga Therapy
Trauma Groups
Other:
Clear selection
How long is your daily practice (in hours)?
Your answer
If you meditate, how long have you been meditating, and how often do you meditate?
Your answer
Approximately what year did you start to practice and/or teach Yoga?
Your answer
Please provide the names of your principal teachers or schools.
Your answer
Do you suffer from any medical condition? Are you taking any medications?
Your answer
If you are under medical treatment or supervision, please tell us about it as thoroughly as you can.
Your answer
Do you have any personal trauma history? If so, please provide details, as well as the healing work that you've done in recovery from your personal trauma.
Your answer
If you are currently receiving psychotherapy, psychiatric treatment, and/or counselling, please tell us about the history and processes you are using currently.
Your answer
If you are using any prescription medication, please indicate type, dosage, and frequency of intake.
Your answer
Are you currently experiencing any injuries?
List all that you think are relevant including chronic and acute.
Your answer
How did you hear about this Private Mentorship Program?
Facebook
Instagram
Class
Website
Flyer
Google Search
Lorraine Taylor
Other:
Clear selection
What is your main interest in taking this Private Mentorship Program?
To become a yoga teacher
To deepen my practice and become a yoga teacher with support
Personal Growth and Development
Career Advancement
Other:
Clear selection
Thank you so much for filling out this registration form! We look forward to journeying with you.
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