Client Intake Form - Ayurveda Information Full Name * First Name Last Name Preferred Pronouns Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Email Address * Date of Birth * MM DD YYYY Profession Medical History Number of Pregnancies * Number of Children Last Date of Menstrual Cycle Do you have any allergies or sensitivities (food/medication)? Please share your present concerns or goals: * Diet Questionnaire Your favorite foods are: * Your least favorite foods are: * Do you feel hungry at mealtime? * Yes No Sometimes Do you over or under eat, or obsess about food/eating? Explain. * Your usual breakfast time: * Your usual breakfast foods: * Your usual lunch time: * Your usual lunch foods: * Your usual dinner time: * Your usual dinner foods: * Are you tired after eating? If so, which meal? * Select the items your regularly use: * White Sugar Caffeine Alcohol Raw Foods Smoking/Nicotine/Other Carbonated Drinks Meat Dairy None of the above How often do you use the items above? Please share anything else you would like me to know about you, or any topics you would like to discuss. Liability Waiver * I, student, voluntarily choose to participate in Yoga and/or Ayurveda sessions with Ho’ola Mamma LLC. This assumption of Risk, Waiver, and Release from Liability covers the entirety of my participation in Yoga and/or Ayurveda sessions with Ho'ola Mamma LLC. 1. Assumption of Risk - I am participating in Yoga and/or Ayurveda sessions with Ho’ola Mamma LLC at my own free will. I assume full responsibility for all risks that may arise out of or result from my participation in the Yoga and/or Ayurveda program, including but not limited to the following: risk of property damage and bodily injury. Specific risks vary from one activity to another and the risks range from minor injuries to major injuries, such as catastrophic injuries including death. 2. Waiver of Liability - I shall be solely responsible for any injury or damage sustained, whether for personal or bodily injury, property damage, death, sickness, disease or otherwise as a result of my use of the programs, equipment, and instructors. 3. I understand that Ho’ola Mamma’s counselors, instructors, teachers, and wellness practitioners are not licensed physicians, surgeons, medical or health care professionals and that no standards or regulations for the practice of Ayurveda and Yoga have been established or defined. Ayurvedic treatment is alternative or complementary to healing art services licensed by the state of California. Ayurveda is not licensed by the state of California or Arizona. 4. I understand that it is not within the scope of this practice for Ho’ola Mamma LLC (and its owners, teachers, counselors, staff members and/or team) to assume responsibility for the treatment of any specific health problems. Ho’ola Mamma LLC has made no claims or representations to the contrary. 5. I understand that photos taken during Yoga and/or Ayurveda sessions and events with Ho’ola Mamma LLC are for promotional and educational purposes only. I grant Ho’ola Mamma LLC permission to take, use, re-use, publish, and republish pictures of me in which I may be included, in whole or in part. 6. Lost or Stolen Items - I will not hold Ho’ola Mamma LLC (and its owners, teachers, counselors, staff members and/or team) liable for any lost or stolen property which may occur. 7. I understand that my health and my healing process requires my active participation and are my own personal responsibility. 8. Cancellation Policy - Reserved sessions may be cancelled without penalty 24 hours in advance of the scheduled session. Each session reservation not cancelled 24 hours in advance of the scheduled session will result in the forfeiture of the credit used to reserve the session. 9. Refund Policy - Single Session, Private Session Package, Group Package and Event/Workshop dues are non-refundable. Sessions and Packages do not expire. I have fully read and fully understand this Assumption of Risk, Waiver, and Release from Liability and understand that it relates to surrendering and releasing valuable legal rights. I do so freely and voluntarily. I have read and agree to the Terms of Service Thank you!
