Client Intake Form

Thank you for booking the Mind, Body & Soul Reset Program.

We aim to provide a safe, comfortable and inclusive environment for you, so we thank you for completing the required information below. This is not group therapy and at no time will you be asked to share personal information with the group.

Please use this form to provide information that you would like us to know. You are not obliged to divulge anything regarding your health or personal circumstances. Anything you choose to share will be treated as confidential under the Privacy Act.

If you have any questions please feel free to contact Jo on 0432550551.

We can't wait to share this space with you.

Jo & Helen

Full Name

Date Of Birth

Emergency Contact Name and Number

Is there anything you would like us to know specific to your own health or circumstances?

Wild Heart Yoga Tribe studio is a beautiful venue. It has 2 short staircases. Will you require assistance to navigate the stairs? We will make arrangements for that.

Do you suffer from Schizophrenia, Personality Disorder, Bipolar Disorder, Major Depressive Disorder?

Any further information you would like us to know?

Terms and Conditions

1. I understand that this course does not provide medical advice, nor is it a substitute for medical or professional assessment or treatment.

2. I understand it is my responsibility to consult with my own GP or specialist regarding suitability to attend this course, where necessary.

3. I understand it is my responsibility to inform the course facilitators of any special requirements or caveats to participation.

I agree to the terms & conditions

Your Signature

Thanks for submitting!