Forms

Before your first class or appointment with me, it’s important that I have some basic information about you.

Please complete and submit my client intake form below.

This is very important so that I am informed about your goals, your body, your previous experience, past and current related activities, and any health issues I should know about when we work together.

If you have questions, give me a call at the number above or contact me directly through the website.

Thank you!

Please Complete The Form Below

* indicates required field

Name:*

Email:*

Subject:*

Message:*

Date of Birth:*

Street Address:*

City:*

State:*

Zip Code:*

Preferred Phone Number:*

Occupation:*

Referred By:*

Emergency Contact:*

Please indicate any history of acute or chronic condition, disease, or injury: (Check all that apply)

Chronic pain
Chronic illness
Neck, Shoulders, Hips, Knees, Ankles, Spine, Wrists
Dislocation of any joint
Broken bones within the past 4 months
Overweight by more than 20 pounds
Pregnancy within the past 4 months
Surgery within the past 4 months
Smoking habit
Arthritis
Asthma
Diabetes
Lungs / Respiratory problems
Gastrointestinal disorder
Headaches
Heart problems
High / Low Blood Pressure
Vertigo

Other:

Please explain any of the above:

Please describe your current exercise regimen:*

Hobbies:*

By entering my name below I affirm the above information to be true to the best of my knowledge.*

 

Informed Consent / Liability / Policies

 

Informed Consent:

Programs led by Melissa Feldman are designed to cultivate self-awareness, balance, focus, strength, flexibility, muscle tone, coordination, relaxation, and proper body alignment. They include but are not limited to yoga, shiatsu, movement, stretching, meditation, visualization, and breathing exercises. Your commitment to one or more of these programs will help maintain a healthy and physically fit lifestyle. Before beginning any therapeutic or exercise program, it is important that you discuss the program with your physician. In addition, please discuss any limitations and concerns you have about your capabilities with Melissa prior to beginning your session or program. I hereby affirm that I am in good physical condition and, to my knowledge, do not suffer from any disability that would prevent or limit my participation in the chosen program or I have obtained approval and counsel from my physician in order to participate in the chosen program.*

Please Initial Here

 

Waiver of Liability:

Participation in programs led by Melissa Feldman is done at your own risk. I understand that my participation in any of these activities can result in injury or illness. I assume full responsibility for any injury, illness, damage, or other claim that may occur as a result of my participation in a program led by Melissa Feldman, and I hereby release Melissa Feldman from any liability now or in the future from any injury, soreness, or illness however caused including active or passive negligence, occurring during or after my participation in a program led by Melissa Feldman. This waiver acknowledges that you are solely responsible for any and all costs, damages, and expenses incurred as a result of any injury sustained when taking part in a program led by Melissa Feldman.*

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I understand that programs led by Melissa Feldman are not substitutes for medical assessment or treatment. I hereby affirm that I have read and fully understand the above.*

Please Sign Name Here

 

Refund Policy for Classes and Workshops:

Fees will not be refunded for any missed classes or workshops.

Please Initial Here

 

Cancellation Policy:

For Private Classes if you cancel less than 24 hours in advance of your scheduled appointment, you will be responsible for 50% of the fee. If you do not show up for your appointment, you are responsible for 100% of the fee.

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