Name
First Name
Last Name
Gender pronoun/s?
Birthdate
Address
Phone Number
(###)
###
####
Email
*
Occupation
Why are you here?
Yoga history: What kind of yoga have you practiced, and for how long?
If you attended classes, what did you like about them, and is there anything that you didn't like?
What are your main three goals with yoga therapy?
Anxiety
Arthritis
Back Pain / Injury - Lower
Back Pain / Injury - Middle
Back Pain / Injury - Upper
Neck Pain / Injury
Blood Pressure - High
Blood Pressure - Low
Broken Bones - which bones and when?
Depression
Diabetes
Disordered Eating
GI Tract Imbalance
Headaches
Heart Disease
Insomnia
Joint Problems / Pain
Pelvic Health - Incontinence
Pelvic Health - Pain
Pelvic Health - Organ Prolapse
Post Traumatic Stress
Respiratory Condition
List any scars and when you got them
List any surgeries and when you had them
Vertigo
Are you Pregnant?
Please list any supplements or medications you take
Is there any other health information you'd like to share?
Were you referred by a practitioner? If so, please include there name and contact information. If not, how did you hear about my services?
What time do you wake up? What time do you go to bed, and what time do you fall asleep?
Do you wake up feeling rested?
When do you eat breakfast? Give an example or two of what you eat.
When do you eat lunch? Give an example or two of what you eat.
When do you eat dinner ? Give an example or two of what you eat.
What about snacks?
How many hours a week do you work?
How many hours a week do you drive?
How many hours a week do you spend on a computer?
How many hours a week do you have outside/in nature?
Have you received a COVID vaccination?
Liability Waiver
*
By selecting "yes" I hereby agree to the following: 1. That I am participating in Yoga Classes, Health Programs or Workshops offered by Light Wellness LLC and/or Emily Light during which I will receive information and instruction about yoga and health. I recognize that yoga requires physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. 2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in the Yoga Classes, Health Programs or Workshops. I represent and warrant that I am physically fit and have no medical condition, which would prevent my full participation in the Yoga Classes, Health Programs or Workshops. 3. In consideration of being permitted to participate in the Yoga Classes, Health Programs and Workshops, I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which I might incur as a result of participating in the program. 4. In further consideration of being permitted to participate in the Yoga Classes, Health Programs and Workshops, I knowingly, voluntarily and expressively waive any claim I may have against Light Wellness LLC and/or Emily Light for injury or damages I may sustain as a result of participating in the program. 5. I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue Light Wellness LLC and/or Emily Light for any injury or death caused by negligence or other acts. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. I am aware that Light Wellness LLC/Emily Light is here to serve me by sharing knowledge of yoga and health. By my participation in classes or activities with Light Wellness LLC/Emily Light, I agree to take full responsibility for not exceeding my limits in the practice of yoga and for any injury I might suffer in the practice of yoga. It is my responsibility to ascertain that there is no medical reason to prevent my participation. In consideration of Light Wellness LLC/Emily Light’s instruction, I waive any claim that I might have at any time for injury of any sorts against Light Wellness LLC/Emily Light or any person or entity in any way involved therewith. I have carefully read the release, fully understand and agree to the above.
Confidentiality
*
I am committed to maintaining respectful relationships with my students and clients. I recognize that you may engage my support for matters that are personal and considered confidential. Information shared with me during your sessions are considered confidential. As a Yoga Therapist, and a Holistic Nutritionist, I do not work under the guidelines of HIPPA. You can sign a HIPPA document with your other healthcare providers, which gives them permission to speak with me. Then, as a team, we can all create a plan to help you thrive in your life.
Payment
*
Payment: I accept cash, check, Venmo, and credit card, and prefer cash, check or Venmo, whenever possible. Payment is due at the time of service. If you purchase a package, payment is due in full at the time of the first session in the series.
Missed Appointments and Cancellations
*
I have a 24-hour cancellation policy. Appointments canceled with less than 24 hours notice will be charged in full, unless the appointment is rescheduled within one week. Appointments canceled with 24 hours or more notice will not incur a charge.
Insurance
*
Please note, I do not participate in insurance plans, including Medicare. Because I don’t participate in insurance plans, I cannot contact your insurance company regarding Superbills, coverage of services, any questions you may have regarding your coverage and etc. If you would like to submit your appointment to your insurance company, I am happy to provide you with a receipt of payment for services. Please be aware that some – and perhaps all – of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers.
