Guiding Starr Yoga Waiver Name * First Name Last Name Email * Phone * (###) ### #### I understand that yoga therapy is provided for the basic purpose of stress reduction in the form of breath work, relief of muscular tension/weakness through movement, and to support healing the connection between mind, body and spirit, through dialogue and exploration of the teachings of yoga. I further understand that yoga therapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, or other qualified medical specialist for mental or physical ailments that I am aware of. * Initial below I understand that yoga therapists are not qualified to, diagnose and/or prescribe, and that nothing said in the course of the session should be construed as such. Because the physical practice of some yoga postures is contraindicated under certain conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I forget to do so. * Initial below Guiding Starr Yoga, explanation of fees for service: Patients are responsible for full payment at the time services are rendered. All professional services rendered are charged to the patient receiving care. 20 minute consult: Free // One 90-minute consult with three 1-hour follow-ups: $425 // Three 1-hour sessions: $300.00 // 90 minutes: $165.00 1 hour: $110.00 // Missed/Cancellation Appointment Policy I require a 12 hour notice of cancellation of Guiding Starr Yoga Therapy Appointments. Appointments missed or cancelled without sufficient notice will be charged the cost of a one hour session. * I have read, understood, and agreed to the fees and payment obligations as listed above. Initial below. I hereby state that all written records, statements and personal information disclosed by the client is protected and will remain confidential. In the case where it is deemed necessary and of interest to the client to share records with other health-care professionals I will only do so with the expressed permission of the client. * Initial below I understand that yoga is a physical exercise and acknowledge that participation in yoga therapy involves some risk. I also understand that these yoga therapy sessions are virtual on zoom, and I agree to release, hold harmless and indemnify Guiding Starr Integrated Yoga and the therapist from all claims including negligence, which arise out of participation in treatment. This release is binding as to any other persons including heirs, executors or family members. * Initial below Electronic signature * Type name below Date * MM DD YYYY By checking this box and typing my name below, I am electronically signing this consent form * Yes, I consent No, I do not consent Thank you!
