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My Account
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0
Services
YOGA
Online
In Person
Prices + Packages
On Demand Library
Forms
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Testimonials
Gallery
Contact
Blog
Forms
Choose your intake form:
private Prenatal / Postnatal / Baby & Me
Prenatal / Postnatal / Baby & Me Yoga Intake Form
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Preferred Pronouns
*
Email
*
How many weeks into your pregnancy or postpartum are you? (please specify)
*
What are you looking to experience or gain out of private yoga classes during pregnancy or postpartum?
*
Personal Yoga Interests:
*
Check all that apply.
Flow yoga (vinyasa)
Strength work (asana)
Restorative yoga
Pelvic floor yoga
Stretching
Concentrated rest (Yoga Nidra)
Breathing practices (Pranayama)
Meditation
Chanting (Mantra)
Yoga Philosophy
Affirmations
Āyurveda (Lifestyle choices)
Acupressure (and self-touch)
Have you practiced yoga before? If so, what type of yoga and for how long?
*
ex. of types of yoga: hot yoga, power yoga, vinyasa yoga, restorative yoga, meditation, pranayama (breath practices)
Are you experiencing any physical injuries, illnesses, or pregnancy/birth experience complications?
*
Have you experienced any injury in the past that is affecting your daily life or could potentially affect your practice?
*
How are you currently feeling in general? Any pain? If yes, where are you feeling pain?
*
How do you rate your current level of activity?
*
Sedentary / Inactive
Somewhat inactive
Average
Active
Very active
On a scale of 1-10, how would you rate your level of stress?
*
1 being not stressed at all, 10 being highly and frequently stressed
1
2
3
4
5
6
7
8
9
10
Are you interested in online or in person private sessions?
*
Online (zoom)
In Person (NYC)
What is your availability for classes? Please list days/times in order of preference.
*
How did you hear about me and my offerings?
*
Anything else you'd like me to know?
By participating in live-stream, in person or recorded Yoga classes, you are agreeing to the following: I understand that all physical activity involves a risk of injury, and that I must receive clearance from a licensed medical health care provider to participate in yoga. I desire and agree to participate in yoga, and I acknowledge that my participation is entirely voluntary. I understand that yoga lessons, yoga private sessions, and yoga professionals do not diagnose diseases or any physical or mental disorders, nor do they prescribe or replace medical treatment. All yoga classes, sessions, and programs do not constitute or replace medical advice. I understand that yoga is not intended to diagnose, treat, cure or heal any illness, and that yoga professionals, such as Chelsea Daniel, do not purport to do so in any capacity. I understand that it is my responsibility to seek medical care if needed, and that yoga may augment such care, but is never intended to replace medical care. I have read, understood, and agree to the content of this Liability. I hereby release Chelsea Daniel and Chickadee Yoga, and any/all representatives from any and all liability for injury or illness in relation to yoga sessions, classes, and trainings. Electronic Signatures: This agreement and related documents entered into in connection with this agreement are signed when a party’s signature is delivered by facsimile, email, or other electronic medium. These signatures must be treated in all respects as having the same force and effect as original signatures.
*
Please type your full name as your signature:
Today's Date
*
MM
DD
YYYY
Thank you!
Private Basics / Hatha / Vinyasa / chair / restorative Yoga
Private Basics / Hatha / Vinyasa / Chair / Restorative Yoga
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Preferred Pronouns
*
Email
*
Have you practiced yoga before?
*
How long have you been practicing yoga?
*
If you currently practice yoga, how often do you practice yoga? (ex. 1-2 times a week for 30 minutes)
*
Personal Yoga Interests:
*
Check all that apply
Flow yoga (vinyasa)
Strength work (asana)
Restorative Yoga
Stretching
Concentrated rest (Yoga Nidra)
Breath work (Pranayama)
Meditation
Chanting (mantra)
Yoga Philosophy
Affirmations
Āyurveda (Lifestyle choices)
Acupressure (and self-touch)
If you currently practica yoga, what type? If you do not practice yoga, write N/A.
*
ex: slow flow, vinyasa, power yoga, hot yoga, restorative yoga, meditation, pranayama (breath practices)
What specifically do you wish to gain from yoga classes with me (i.e. flexibility, concentration, balance, stress relief, mobility, strength, functional movement for daily life)?
*
How are you feeling overall? Any past injuries or current health conditions that affect your daily life or could affect your practice?
*
How do you rate your current level of activity?
*
Sedentary / Inactive
Somewhat inactive
Average
Active
Very active
On a scale of 1-10, how would you rate your level of stress?
*
1
2
3
4
5
6
7
8
9
10
Are you interested in online or in person private classes?
*
Online (zoom)
In person (NYC)
Anything else you'd like me to know about?
By participating in live-stream, in person or recorded Yoga classes, you are agreeing to the following: I understand that all physical activity involves a risk of injury, and that I must receive clearance from a licensed medical health care provider to participate in yoga. I desire and agree to participate in yoga, and I acknowledge that my participation is entirely voluntary. I understand that yoga lessons, yoga private sessions, and yoga professionals do not diagnose diseases or any physical or mental disorders, nor do they prescribe or replace medical treatment. All yoga classes, sessions, and programs do not constitute or replace medical advice. I understand that yoga is not intended to diagnose, treat, cure or heal any illness, and that yoga professionals, such as Chelsea Daniel, do not purport to do so in any capacity. I understand that it is my responsibility to seek medical care if needed, and that yoga may augment such care, but is never intended to replace medical care. I have read, understood, and agree to the content of this Liability. I hereby release Chelsea Daniel and Chickadee Yoga, and any/all representatives from any and all liability for injury or illness in relation to yoga sessions, classes, and trainings. Electronic Signatures: This agreement and related documents entered into in connection with this agreement are signed when a party’s signature is delivered by facsimile, email, or other electronic medium. These signatures must be treated in all respects as having the same force and effect as original signatures.
*
Please type your full name as your signature:
Today's Date
*
MM
DD
YYYY
Thank you!
Park yoga consent form
Park Yoga Consent Form
Name
*
First Name
Last Name
Email
*
How did you hear about Chickadee Yoga + Birth park yoga classes?
*
Google
A friend
Chelsea
Fliers
Would you like to be added to our mailing list to receive updates on special classes, upcoming YACEP® courses and trainings led by Chelsea?
*
Yes
No, thanks
By participating in live-stream or recorded Yoga classes, as well as in-person private and/or in person group sessions, you are agreeing to the following: I hereby release Chickadee Yoga + Birth, Chelsea Daniel, and any instructors from responsibility for any injuries I may sustain as a result of participation in the classes or programs presented by Chickadee Yoga + Birth - including any in-person, online pre-recorded or live-streamed class. I am aware that the instructor cannot see me during virtual sessions and may not be able to offer personalized instruction, and therefore I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which I might incur as a result of participating in the classes or programs offered through Chickadee Yoga + Birth. As determined by my physician and myself, I certify that the level of my physical condition will allow me to safely participate in programs at Chickadee Yoga + Birth. I have read the above release and waiver of liability and fully understand its contents. I am legally competent to voluntarily agree to the terms and conditions stated above, and by providing my electronic signature below agree to these conditions.
*
Electronic Signature
Thank you!
