New Client Form | Bellarine Yoga Therapy

Yoga Therapy Health & Wellbeing Form

Thank you for booking and confirming your session! To help us prepare for our time together, please complete the following steps before your appointment:

Step 1: Complete this Health & Wellbeing Form so your session can be fully tailored to your goals and needs.
Step 2: Review our Privacy Policy to understand how your information is protected.
Step 3: Read and check the sign waiver box
Click Submit

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Bellarine Yoga Therapy - New Student Intake & Waiver Form

Welcome to your yoga therapy journey.

Please allow 15-20 minutes to complete this form so we can tailor our sessions to your unique needs, health history, and goals.

All information provided is kept strictly confidential and helps ensure your practice is safe, comfortable, and supportive. Feel free to share as much detail as you feel comfortable with.

To ensure I have enough time to review your information and prepare for our session, please complete this form at least 48 hours prior to your first Yoga Therapy appointment.

If you have any questions relating to this form please feel free to contact me directly.

Alex Evans

Yoga Therapist

Bellarine Yoga Therapy

0438854489

alex@alexevans.com.au

Personal Details

First name

Last name

Phone

Join our mailing list

Yes please

Date of Birth

Day

Month

Year

Age

Country of Birth

Preferred Communication Method

Phone

Text

Other

Emergency Contact (Name & Phone):

Relationships

Describe your relationship status and living arrangements

Describe your social & support network

Describe your Hobbies and Interests

Occupation

Occupation

Occupational body position - most common.

Sitting

Standing

Mobile

Other

Has your occupation changed in the last two years (why?):

Health & Wellness Profile

Describe your current energy levels throughout the Morning

Low

Medium

High

Excessive

Describe your current energy levels throughout the Afternoon

Low

Medium

High

Excessive

Describe your current energy levels throughout the Evening

Low

Medium

High

Excessive

Describe your sleep pattern in terms of onset, quality and duration

Fitness level

Beginner / Low Active — I am new to exercise/yoga or engage in minimal physical activity (light walking, minimal movement).Moderate — I engage in light to moderate movement 1–3 times per week (walking, gentle fitness, occasional yoga).

Moderate — I engage in light to moderate movement 1–3 times per week (walking, gentle fitness, occasional yoga).

Active — I exercise regularly 3–5 times per week (cardio, strength, dynamic yoga, or sports).

Advanced / Highly Active — I engage in vigorous physical training or an advanced daily practice 5+ times per week.

Other

Diet - Describe your diet, appetite and eating patterns

Alcohol - Describe an average weekly intake

Bowel movements

Regular

Irregular

Constipated

Other

Are you currently pregnant or postpartum?

Yes

If you answered yes to anything above please let me know relevant details

Personal Medical History & Treatments Please list significant illness/Musculoskeletal problems/Mental Health concerns/trauma/past surgeries that are not described above.

Family Medical History Please list who and when

Current medications and dosage

Other treatments - Are you currently receiving any other treatments? eg physio, acupuncture, chiro etc and what are you doing?

Any other relevant lifestyle and medical Information not covered in this form

Yoga Therapy

What is your primary reason for seeking Yoga Therapy today? (e.g., physical injury, chronic pain, stress management, respiratory issues, emotional support)

Describe how the above affects you in your daily life?

What are your short-term goals for Yoga Therapy (next 4 weeks)?

What are your long-term goals for Yoga Therapy (6+ months)?

Have you practiced yoga before?

Never

Occasionally

Regularly

When is the best time of day for you to practice?

Morning

Afternoon

Evening

Other

Are you comfortable with the following Yoga tools?

Chanting/Sound

Yes

Unsure

Breathwork/Pranayama

Yes

Unsure

Visualisation/Meditation

Yes

Unsure

Kriya Yoga

Yes

Unsure

Do you have any questions relating to this form?

Privacy statement

Your privacy and trust are fundamental to our work together. This Privacy Policy outlines how your personal and health information is collected, used, and protected during our yoga therapy sessions.

1. Collection of Information To provide safe, personalized, and effective yoga therapy, I collect relevant personal details, health history, lifestyle information, and session progress notes. This information is gathered directly from you through intake forms, consultations, and ongoing sessions.

2. Confidentiality & Storage All client records, health notes, and personal communications are strictly confidential.

Personal and health records are stored securely using encrypted, password-protected digital storage or locked physical files.

Access to your personal data is restricted solely to your yoga therapist.

3. Disclosure & Consent Your personal information will never be sold, rented, shared, or disclosed to third parties—including other healthcare providers, family members, or institutions—without your explicit written consent.

4. Exceptions to Confidentiality In alignment with professional standards similar to counseling and healthcare professions, confidentiality may only be broken without your consent under specific legal or ethical obligations:

Harm to Self or Others: If there is a serious, imminent risk of harm to yourself or another person.

Unlawful Activity or Abuse: If details of unlawful activity come to light, including child abuse, elder abuse, or serious illegal acts requiring mandatory reporting by law.

Legal Requirements: If records are formally subpoenaed or requested under legal court order.

In the rare event that disclosure is legally or ethically required, every effort will be made to discuss the situation with you beforehand, provided it is safe and legally permissible to do so.

5. Your Rights You have the right to request access to your personal records, ask for corrections to inaccurate information, or request the deletion of your personal data, subject to legal record-retention requirements.

If you have any questions or concerns regarding how your information is handled, please feel free to discuss them prior to or during your session.

Participant Waiver of liability and Informed Consent

Please read and sign below:

Inherent Risk: I understand that yoga includes physical movements as well as an opportunity for relaxation, stress reduction, and relief of muscular tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated.
Personal Responsibility: I acknowledge that it is my responsibility to consult with a physician prior to and regarding my participation in the yoga classes offered by Bellarine Yoga Therapy. I represent and warrant that I am physically fit and that I have no medical condition that would prevent my full participation in the class.
Instruction & Limits: I understand that if I experience any pain or discomfort, I will listen to my body, adjust my posture, and ask the instructor for support. I will continue to breathe smoothly. I agree to follow the instructor's guidance but recognize that I am the ultimate judge of my physical capability.
Release of Liability: In consideration of being permitted to participate in the yoga classes, I knowingly, voluntarily, and expressly waive any claim I may have against Alex Evans and Bellarine Yoga Therapy for injury or damages that I may sustain as a result of participating in the program.
Data Privacy: I understand that the information provided on this form is confidential and will only be used to tailor my yoga instruction safely.

Bellarine Yoga Therapy philosophy of personal responsibility:

Personal Responsibility: I understand that Yoga Therapy is a self-empowering process where I take responsibility for my own health through a committed personal practice.
Medical Disclaimer: I understand that Yoga Therapy is a complementary health modality and not a substitute for medical advice or treatment.
Consistency: I acknowledge that to experience the benefits of a practice, it must be practiced regularly as prescribed.

Terms Acknowledgment & Digital Signature

By checking this box and submitting this form, I acknowledge that I have read, understood, and voluntarily agree to all terms of the Privacy Policy, Participant Waiver, and Informed Consent. I agree that checking this box acts as a legally binding digital signature equivalent to my handwritten signature.

I have read and agree to the terms outlined above.

Today's Date

Day

Month

Year

Thank you for honoring your health and taking the time to complete this form. Your responses allow us to craft a practice tailored to your unique needs and well-being.