Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Please make note of any physical or emotional concerns that may arise during sessions Please advise if you require any accomodations Please list any allergies, sensitivities, and intolerances, including to food and scents (e.g. essential oils, incense, etc.) Is there anything else we should be aware of? How did you hear about us? Google Social Media Word of Mouth Other Acknowledgement & Waiver of Liability * By clicking the checkbox below, I agree and understand that: I am here on my own behalf and of my own free will. The services performed by Lumi Yoga and any affiliates are not intended as a substitute for professional medical or mental health care and do not involve diagnosis, treatment, prescribing for treatment of disease or any act for which a medical license is required. I am now being advised that if I have any health problems, including mental illness or other health conditions or diseases I should not postpone or delay in getting competent medical advice from a primary care physician or licensed mental health professional. I understand and agree that any services are not designed to cure or prevent any disease, pain, deformity, injury, or mental or physical condition of any kind. I assume full responsibility during and after my participation, for my choice to use or apply, at my own risk, any portion of the information or instruction I receive. I understand and agree that my personal information and anything discussed in my sessions is strictly confidential, and that my results are partially upon my own willingness and ability to apply the recommendations and personal homework I receive. I am now being advised that side effects, although uncommon, are possible when taking part in Yoga, Yoga Nidra, and other Mindfulness & Wellness Techniques. In the unlikely case of a reaction that is overwhelming, or beyond my own capacity to handle, I will not hesitate to contact a licensed physician or a qualified mental health counsellor. 24 hour mental health services in Ontario can be found by calling 1-866-797-0000. Lumi Yoga and affiliates assume no liability for any personal loss, damage, or injury as a result of your participation in programs designed by them. I agree and understand Thank you!
