Private Yoga 1:1 Kitchener & Online | Flow Space Studio

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Movement Studio

Movement Studio

Movement Studio

New Client Intake Form

Let’s connect before we get started!

We’d love to learn more about you, your aspirations and goals with Yoga and how we can best support your flow journey. Before your first session, please complete the intake form below and we’ll see you at practice ❤

Name *

First Name

Last Name

Email *

Select Service *

Have You Practiced Yoga Before? *

Yes, but I'm still relatively new

Yes, for a long time

No, this is new for me

Your Why Message :) *

Date of Birth *

MM

DD

YYYY

Any injuries, pain, limited range of motion, restricted movements, etc. to disclose before we start *

Health History *

Please review and select all conditions you have experienced (past and/or present)

Dislocated/Broken Bones

Muscle Strain

Ligament / Tendon Sprain

Arthritis / Bursitis

Disc / Back Issues

Scoliosis

Osteoporosis

Arthritis

Knee Issues

Ankle Issues

Shoulder Issues

Wrist Issues

Neck Issues

Cardiovascular Conditions / Chest Pain

High Blood Pressure

Low Blood Pressure

Diabetes (type 1 or 2)

Epilepsy / Seizures

Anxiety / Mental Health Conditions

Insomnia / Trouble Sleeping

Asthma / Short Breath

Cancer

Stroke

Numbness / Tingliness anywhere

Pregnancy (past)

Pregnancy (current)

Autoimmune Disease

Please list any allergies or sensitives you have *

While At Work / Most of My Day I Spend *

Your Current Activity Level *

Sedentary / Very Inactive

Somewhat Inactive

Average

Somewhat Active

Extremely Active

How Often do You Exercise *

None

1-2 Days per Week

3-5 Days per Week

6-7 Days per Week

Forms of Exercise You Do Regularly (if applicable) *

Availability *

please select when you're available to practice

Monday

Wednesday

Availability *

Morning

Afternoon

Evening

Areas You want to work on *

Strength & Mobility

Flexibility

Breathwork

Mindfulness

Do you consent to hands-on assists? *

Yes

No

How did you find us?

Thank you! We are SO excited to get started, keep your eyes peeled for an email from us soon!

Email Address

Thank you!

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Land Acknowledgement :

Flow Space Studio acknowledges that the land in which we move on is the unceded, ancestral lands of Anishinabewaki ᐊᓂᔑᓈᐯᐗᑭ, Ho-de-no-sau-nee-ga (Haudenosaunee), Attiwonderonk (Neutral), Mississauga, and Mississaugas of the Credit First Nation peoples; also part of the Haldimand Tract, land promised to Six Nations of the Grand River which includes six miles on each side of the Grand River.