Chakra Balancing Session 2023 |

Name *

First

Last

Email *

Phone *

Please read each statement and check each box to signify your understanding: *

I understand that somatic yoga therapy is provided for pain relief, stress reduction, relief from muscular tension, and improvement of circulation and energy flow.
For in-person visits, I give the provider my permission to provide hands-on assistance as needed to evaluate my situation and guide the recommended somatic yoga therapy movements.
I understand that the services offered are not a substitute for medical care. I understand that the provider is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
I affirm that I will notify the provider of all known medical conditions and injuries.
By signing this release, I hereby waive and release the provider from any and all liability, past, present, and future relating to the somatic yoga therapy sessions.

Type your full name to confirm you understand the statements above: *

What's your past experience (if any) with chakra work? *

What is your hope for this session? *

Are you living with emotional, mental, spiritual, or physical distress? If so, please describe. *

Are you currently receiving any body or energy work?

What haven't I asked that you'd like me to know?

Do you have questions for me? I'll either answer them via email or at your first appointment.

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