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Reflections Yoga and Wellness
Complete the form, sign and submit.
Please check any that apply and provide details as needed.
Musculoskeletal issues (e.g., back pain, joint injuries)
Heart conditions or high/low blood pressure
Respiratory issues (asthma, COPD, etc.)
Recent surgeries or medical treatments
Anxiety, depression, or emotional challenges
Pregnancy (current or recent)
Other (Please explain below)
What would you like to focus on during your private sessions?
Stress reduction
Pain relief or physical recovery
Building strength or flexibility
Improving posture
Breath awareness and control
Mindfulness or meditation
Emotional healing or balance
Other (please specify below)
Other Goals or Intentions:
Are you comfortable with hands-on adjustments or would you prefer verbal cues only?
Would you be interested in integrating Reiki, sound healing, or meditation into your session?
Anything else you'd like your instructor to know?
I acknowledge that yoga is a personal journey and I take responsibility for my health and well-being during sessions. I have answered these questions truthfully to the best of my ability.
By E-signing this form, you agree to the following:
I understand my consent for a private yoga session is informed and voluntary and I may withdraw my consent at any time except for actions already taken.
I understand that I or the private yoga instructor may terminate the session at any time.
I release the private yoga instructor and Reflections Yoga and Wellness LLC from all liability for any harm that may unintentionally result from any private yoga session.
