Client Intake Assessment

Name

First Last

Date of Birth

Email

Phone (Day)

Phone (Evening)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referred By

Emergency Contact Name

First Last

Emergency Contact Phone

How did you hear about me and Lofty Heights Movement?

Have you done yoga before?

Where?

Are you sensitive to fragrances?

Are you sensitive to physical touch?

List any allergies you have

List any medications you are currently taking

List any medical conditions you think I should know about including but not limited to heart, brain, respiratory, mental health, anxiety, etc..

What is your goal for this session?