Release & Intake Form – Lokananda® Yoga

Name *

First

Last

Date of Birth *

Age *

Email *

Address *

Phone *

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Relationship *

Do you have any medical conditions? *

Yes
No

If yes, are you under medical supervision? *

Yes
No

If yes, please give us a few details

Are you on any medications? *

Yes
No

If yes, please list all current medications (dosages and length of time taken)

Do you experience any allergic reactions? *

Yes
No

If yes, please list

Are you seeing a mental health professional? *

Yes
No

If yes, please tell us what for

Do you drink or use substances on a regular basis? *

Yes
No

If yes, what do you use? How often? And how much?

Do you smoke? *

Yes
No

If yes, how often and how much?

Do you take supplements? *

Yes
No

If yes, pease list

Do you have any tendencies towards low (hypoglycemia) or high ( diabetes) blood sugar? *

Yes
No

Please list any previous experience(s) with plant medicine (if adverse effect please note)

What is your intention for attending this session? (please share a brief explanation) *

Agreements *

I attest the above to be true.

I agree to the commitments below (please scroll to read all of them). *

I hold myself responsible for my own well being.

I agree to stay in communication with my facilitator if or when I feel that my needs are not being met.

I agree to hold the session, the participants and the container /environment with respect, compassion, and tolerance for others actions and words.

I agree to keep all conversations and actions of the participants strictly confidential. Sharing through speech, written word, and/or publishing of any information experienced, heard or seen is prohibited.

I agree to turn off all cell phones, internet devices, tracking devices and other forms of electronic signal transmission. (This serves the privacy of the container/environment but also supports the communication with nature and nature’s elements.)

I agree if I would like to refer someone to this work, I will speak primarily of my own personal experience and only when appropriate. I will refrain from the use of other participants’ names.

I agree to keep any referrals to this work inside my inner circle and to people who I trust with this type of work. (Referrals are appreciated.)

I understand that this work can be life changing. I will take responsibility for self care prior to, during and following our time together.

I agree to stay at the session until the integration meeting is complete.

I understand that integration is an ongoing process. Our facilitators are available for complimentary 15 minute calls and full integration sessions are available upon request for an additional rate.

If I have an issue or disagree with any of the above statements, I agree to speak with a facilitator before proceeding with the ceremony.

Our Agreements with you *

We agree to the commitments below.

We devote ourselves to creating a safe and nurturing container/environment that supports transformational experiences. We agree to hold space for your process with compassion and presence, to the best of our ability. We agree to uphold confidentiality with your personal process, information and any/all experiences during the session.