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GemLight Education, Yoga and Wellness Intake Form
Share some information about you and what brought you here today. We will find the program that best suits you and your needs!
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Email
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Your email
Name
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Phone number
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Why are you seeking support from GemLight Yoga, Education and Wellness?
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Do you have any physical ailments or injuries?
Your answer
Have you ever taken Yoga, Meditational, or Breath work classes before? If so, explain the type of practice (e.g. Hatha Yoga, 4-7-8 breath work, mindful education in after school programming, etc.).
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How often do you take part in physical activity?
rarely or never
once a week
2-3 times a week
regularly
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What types of physical activity do you take part in?
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What challenges do you experience when dealing with your mental, physical or emotional health?
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What types of practices do you find successful or helpful for your mental, physical or emotional health?
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Which service(s) are you interested in?
Yoga
Breath work and Meditation
Mindfulness and Environmental Education for Children
Private classes
Events
What is your intention for this practice (e.g. weight loss, strength, relaxation, mental health, etc.) ?
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Do you have any questions or comments? Please share your thoughts below;
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