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Reflections Yoga and Wellness

Private Trauma-Informed Movement Session Intake Form (child)

Contact Information

Complete the form, sign and submit.

Parent/Guardian Name/Relationship*

Child's Name *

Child's DOB*

Month

Day

Year

Parent/Guardian Email*

Parent/Guardian Phone Number*

Emergency Contact Name*

Emergency Contact Phone*

Daily Life & Social Functioning

Daily routine: school, naps, screen time, physical play, etc.*

Social Skills: Interaction with peers/adults*

Emotional & Behavorial Regulation

Known triggers or stressful situations?*

Coping strategies used (deep breathings, comfort items, movement, drawing)?*

Childhood nightmares or sleep disruptions (if relevant)?

Health Information

Please check any that apply and provide details as needed.

Recent surgeries or medical treatments

Anxiety, depression, or emotional challenges

Other (Please explain below)

Additional Health Information:

Session Goals

Stress reduction

Pain relief or physical recovery

Emotional regulation

Improving posture

Breath awareness and control

Mindfulness or meditation

Emotional healing or balance

Other (please specify below)

Other Goals or Intentions:

Short answer

Anything else you'd like your instructor to know? Is there any event or situation impacting your childs sense of safety? (you may share as much or as little as feels right; this helps me better support them.

Additional information:*

Consent and signature

I acknowledge that yoga is a personal journey and I consent to have my child participate in movement-based activites.

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.

Signature*

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reflectionsyoganow@gmail.com

Reflections Yoga and Wellness

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