NEW CLIENT FORM

Thank you for your interest in my services.

If you have not yet taken a look at the service you're interested in, please do so before taking the time to fill out this form. Your responses are kept strictly confidential.

I look forward to hearing from you!

~ Jessica

Please complete the new client form below

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

(For class cancellations and communication between sessions as needed)

Country

(###)

###

####

Birthdate

YYYY

I am interested in:

Please check all that apply

Private Yoga Lessons (In Person)

Virtual Private Yoga Lessons (Zoom)

Group Lessons

Occupation

Typical preferred day(s) & time(s) to meet:

Please list all possibilities.

Have you practiced yoga before?

Privately, in a studio or at home all count as 'yes!'

Physically, please describe how you feel on a daily basis.

Mentally and emotionally, please describe how you feel on a daily basis.

What does a typical week look like for you?

Please describe any exercise routine, workload, recreation, schedule...etc.

Where in your body do you feel that you hold the most tension?

What are you hoping to gain, achieve or discover through our session(s)?

Please be as specific as possible. Thank you for your time!

I would prefer my initial consultation be via:

Release & Waiver of Liability

• I understand and appreciate the physical risks involved in a yoga practice and voluntarily assume any and all risks • I am in proper physical condition to participate in this class or event • I agree to release and forever discharge Jessica Richburg from any and all liability for any injury • I understand that if I am unable to keep my scheduled private lesson appointment, I must offer the courtesy of 24 hours advanced notice via phone call, text or email • If I offer less than 24 hours advance notice, I may be charged up to full price of the lesson

NEW CLIENT FORM

Private yoga classes

GROUP CLASSES

Please complete the new client form below