Private Clients

State of Flow Yoga

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{Private Sessions}

New Client Intake Form

* Indicates required field

Name *

First

Last

Email *

Emergency Contact (Name & Phone Number) *

Occupation / Industry *

Age *

Phone Number *

How did you hear about us? *

Internet search (Google) Advertisement Client/Friend Referral Flyer Other

Requested Day(s) for Sessions: *

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

If other, please specify *

Requested Time(s) *

Yoga Experience

Have you practiced yoga before? *

Yes No

If yes, how often *

Everyday Once per week 2-3 time per week Once per month Less than once per month Only once or twice ever

What are your interests in yoga? (Check all that apply) *

Asana (Physical Practice) Pranayma (Breath work) Meditation Yoga Philosophy Yoga for Pregnancy Yoga for ADHD

What style(s) of yoga do you normally practice? (Check any that apply) *

Ashtanga Vinyasa Flow Restorative / Gentle Yin Iyengar Power / Hot Bikram / Hot Hatha/Strong Forest Yoga

Lifestyle & Fitness

What is your current level of activity? *

Very Inactive - Mostly Sedentary Fairly Inactive - Occasional activity Average - Some consistent activity Fairly Active - 2-3 workouts per week Very Active - 4-7 work outs per week

On a scale from 1-10 ( 1 = lowest, 10 = highest) How would you rate your current stress level *

What Activities or Actions do you do daily? (Work AND/OR Leisure) *

What activities or strategies, if any, do you use to combat stress? *

I agree to receiving marketing and promotional materials *

Submit

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