Request Yoga Therapy | The Yoga Shed

Privacy Policy in relation to Yoga Therapy: I understand the following information provided by me will be used for the sole purpose of providing yoga therapy and will be kept confidential. The Yoga Shed will take reasonable steps to protect the personal information we collect and hold from misuse, loss and interference and from unauthorised access and modification, and to make sure it is accurate, complete and up-to-date when we collect or use it. To assist us, please ensure you provide us with your correct details, and let us know if you believe the information we have about you is inaccurate, incomplete, out of date or misleading (and we will take reasonable steps to correct the information). If you are uncomfortable about providing certain information or unsure about why you need to provide it, please let us know so that we can discuss and ensure that you feel completely comfortable before proceeding. *

I understand and accept the Privacy Policy in relation to Yoga Therapy

Name *

First

Last

Email *

Town and postcode

Telephone number (mobile preferred) *

Date of Birth

Emergency contact (name, relationship and phone no. )

What is your chief presenting concern and what is your goal for yoga therapy?

Occupation/domestic duties/carer responsibilities

This question is asked to help identify physical & mental activity that may be taken into account when developing a yoga therapy strategy.

On a typical day do you:

Do any of the following relate to you?

Please elaborate on any of the conditions selected above

Household dynamics for home therapy practice. Do you live alone or with another person/people?

Select below any supports you have in your life

What exercise do you do and how often?

Are you on any medication inc. complementary, herbal or vitamins? What is it's purpose?

Are you currently under the care of

How would you describe your stress levels?

High
Moderate
Low

Do you regularly suffer from feelings of overwhelm?

Yes
No

How would you best describe your sleep patterns?

good
I have trouble getting to sleep
I have trouble staying asleep
other

We'll be in contact shortly to arrange a time for an initial consultation with you, feel free to suggest some times below for your consultation or leave any further comments

Waiver and Release Policy: Waiver & Release Policy: If at any time during the class, you feel discomfort or strain, gently come out of the posture. You may rest at any time during the therapy session. It is important in yoga that you listen to your body, and respect its limits on any given day. I understand that yoga may include physical movements as well as an opportunity for relaxation, stress re-education and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body, discontinue the activity, and ask for support from the instructor. I will continue to breathe smoothly. I assume full responsibility for any and all damages, which may incur through participation. I understand that Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. By signing, I affirm that a licensed physician has verified my good health and physical condition to participate in a yoga program, if required. In addition, I will make the instructor aware of any medical conditions or physical limitations before class. If I am pregnant, become pregnant or I am post-natal or post-surgical, my agreement here verifies that I notified you of this condition and have my physician’s approval to participate. I also affirm that I alone am responsible to decide whether to practice yoga and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against The Yoga Shed and all related facilities and premises for any personal injury or negligence. I verify that I am over 18 years of age. If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from. I have carefully read and fully understand and agree to the above terms of this Liability Waiver Agreement. My agreement to this is voluntarily and I recognise that my agreement and consent here serves as complete and unconditional release of all liability to the greatest extent allowed by law and that it cannot be changed orally. *

I understand and consent to the Waiver and Release Policy

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