Yoga on the Brain ¦¦ Intake
Thank you for filling out this short intake form. This will allow sessions to be catered to each of your needs as we embark on this journey together! You will recieve an email with the class link and a few forms to fill out for this yoga therapy offering.
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Email *
What is your name? *
What is your birthdate? *
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Where are you located in the world? *
What is your emergency contact? (please leave name and number of your emergency contact) *
Briefly describe neurological condition and any relevant past medical history *
Do you have a shunt or other medical device? If so, please describe *
Describe your symptoms as you experience them in your daily life *
What are 2-3 goals you have for yourself and this class? *
Do you have any questions/comments/concerns for me? *
A copy of your responses will be emailed to the address you provided.
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