Client intake for minors |

Minor's Name *

First

Last

Birthdate

Parent/Legal Guardian Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent 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, the provider will not use any hands-on assistance for the minor.
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 of the minor.
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 are you hoping for the minor to achieve with these sessions? *

What's the minor's history of major illnesses, injuries, surgeries? Also provide timeframe of when they occurred if you can. *

Is there additional information you'd like me to have?