Student QuestionnaireYoga for Diverse Abilities - One-on-One Sessions Student's Name * First Name Last Name Date of Birth * Current Age * Your Name (if different than student) First Name Last Name Relationship to student Email * Phone (###) ### #### Are there physical symptoms of your current diagnosis that may effect the yoga practice? * Do you have seizures? Triggers? * How would you describe your child's concentration and attention span? * Who does the child live with? Is your child's motor development delayed? Please describe * How would you describe your child's personality? * Do you have any goals for child's participation in yoga classes? Does your child receive any other therapies? If yes, please list. How does your child respond to new teachers or therapists? Do they take time to warm up to new environments? * What are your child's interests? * Yoga teaches us tools for mental and emotional regulation. Does the student have any tools or techniques that they use now for mental and emotional regulation? * We have a visual guide that shows students the steps of entering the building and getting to the yoga room. Would this be helpful to share with you or the student upon arrival? Yes No, not needed How does the student communicate? * Anything else you would like us to know? Session Policies * Private yoga sessions for individuals with disabilities are $70/session and sessions range from 30-45 minutes. We offer a first time trial session for $35. All sessions must be paid for at the time of booking. We ask for 24 hours notice to cancel or reschedule your appointment. There is a $35 cancellation fee for any appointments rescheduled or cancelled within 24 hours. Some students will acclimate to yoga classes quickly and others may need more time. When a session is scheduled, we are committed to working with students for the entire time; however, if continuing with class seems potentially harmful to the student, space, or instructor, a session may be ended early. In this case, the full session investment will still be required. I Agree I Disagree Thank you! We will be in touch should we have any further questions. Please feel free to contact suzanne@humblehavenyoga.com should you have any additional questions or comments!
