Intake Form (Private Sessions)

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Full Name *

Pronouns

Birthdate

YYYY

E-mail *

Telephone *

City/ Town, Country *

Life Roles (e.g. dietician, grandmother, community volunteer)

Emergency Contact (Full Name and Telephone) *

What are your priority needs and intentions for private therapeutic yoga or nidra therapy sessions? *

Are you utilizing any other treatments or practices to address these needs and intentions? If yes, feel free to describe.

Do you have prior experience with yoga practice(s)? If yes, feel free to describe.

Would you like a custom-designed home practice program? If yes, how many minutes can you commit to daily practice and when (e.g. morning, afternoon, evening)?

(If not mentioned already) are you experiencing any injuries, conditions, or circumstances that you would like Kimberley to be aware of? If yes, feel free to describe.

Feel free to provide any additional comments or questions.

How did you hear about Kimberley's services? *

I understand that yoga practices may serve as complementary wellness tools and not substitutes for professional medical care.

I am responsible for my personal safety during each session, adapting Kimberley's guidance to honour my unique needs and intentions.

I am aware that I might experience sleepiness during the sessions. I will ensure sufficient alertness if I must operate a vehicle or do anything else that requires full attentiveness after each session.

I accept that sessions are non-refundable and valid within four months of purchase. If I am no longer able to attend a session, I should cancel my appointment by contacting Kimberley at least 24 hours before the start time. Otherwise, the session pass will be redeemed.

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All information on this form will be kept confidential.

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