Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Cell Phone Number
(###)
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####
Email
Emergency Contact Name
First Name
Last Name
Emergency Phone Number
(###)
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How did you find Ethereal Crown?
*If selected other, please share how
ASANA (PHYSICAL POSES) EXPERIENCE
Have you practiced Asana Yoga before?
(Date of last class/practice)
MM
DD
YYYY
If yes, continue. If no, skip to MEDITATION EXPERIENCE
What was the setting?
How often do you practice Asana Yoga?
Styles(s) of yoga practiced? (select all that apply)
*if selected other, please share what style(s)
Are there any phrases/sayings/quotes that yoga instructors have said in the past that resonated with you in a positive way? (list as much or little detail as you like)
Are there any phrases/sayings/quotes that yoga instructors have said in the past that rubbed you the wrong way or you perhaps felt triggered by? (list as much or little detail as you like)
Have you practiced meditation before?
If yes continue, if no, skip to BREATHWORK EXPERIENCE
What was the setting?
*if selected other, please share where
How often do you practice meditation? (select one)
Style(s) of meditation practiced? (select all that apply)
*If selected Other, please share what Style(s)
BREATHWORK (PRANAYAMA) EXPERIENCE
Have you practiced breathwork before?
If yes continue, if no, skip to IN SESSION OPTIONS/OFFERINGS
What was the setting? (select one)
*If selected Other, please share the setting
How often do you practice breathwork? (select one)
Technique(s) of breathwork practiced? (select all that apply)
*If selected Others, please share what technique(s)
IN SESSION OPTIONS/OFFERINGS
In a private client environment, I am offering hands on assist during our asana portion of time together, not just for adjusting alignment but also to place subtle pressure on the hips in childs pose, give a temple/neck massage in savasana, other resting postures etc. Do you grant me permission to give you hands on adjustments/ hands on assists in our time together? (Your answer can always be changed later) I ask you inform me before our session together if you do change your mind (check one)
I typically place cool cloths on your forehead in savasana! Please pick your morning, midday, and evening scents so I know what cloths to make for you!
If you want scents, select your morning, midday, and evening scents below
Morning Scent (select one)
Midday Scent (select one)
Evening Scent (select one)
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INTENTIONS
What are your mental/emotional intentions/expectations for your journey to a higher consciousness?
What are your spiritual intentions/expectations for your journey to a higher consciousness?
What are your energetic intentions/ expectations for your journey to a higher consciousness?
What are you hoping to learn about yourself along the way?
Do you have a preferred method for coming into your higher consciousness that you would like to focus on? (i.e meditation, breathwork, centering through mindfulness techniques, asana, etc.)
LIFESTYLE & FITNESS
How do you rate your current level of activity? (select one)
On a scale of 1-10(1 is lowest, 10 is highest) how would you rate your level of stress?
MEDICAL HISTORY
Please review this list and check those conditions that have affected your health either recently or in the past.
Anything NOT listed:
Are you currently pregnant?
Have you EVER HAD any surgeries? If so, list the date(s)
Is there anything else you feel I should know before we begin? Please List anything at all below.
