Ayurveda Application

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Ayurveda Application

Fill out this form to apply to work with Kaya and her Ayurvedic programs or private sessions. This allows Kaya to ensure that she is working within her scope of practice and to take on clients whom she can confidently help.
You may want to look over the questions, and then pay attention to yourself a little more for a few days before returning to fill it out. If the form does not submit, scroll up and find highlighted incomplete fields. Yes, this works from a mobile device.

Your answers go directly to Kaya and remain confidential.

Ayurveda Form for Private Clients and Yogify Applicants

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

I am interested in *

Group Ayurveda Classes A private consultation in Ayurveda with Kaya Both!

Exposure to Ayurveda *

None I have read some books / articles I have done a dosha quiz I have seen a practitioner before I have had ayurvedic bodywork before I already have an Ayurvedic Lifestyle and Diet I have some information but am not using it in my life

Click all that apply

Main Health Concern(s) You would Like to Address with Ayurveda *

Other kinds of modalities you have tried / are currently engaged in *

Acupuncture Chiropractic Massage Ayurveda Herbs Homeopathy Allopathic (Western / Modern) Medicine Yoga Meditation Exercise Other None

Click all that apply

Describe your general diet - eg. vegetarian, vegan, high protein, paleo, meat eating, generally unhealthy, eat out frequently, home cooked food, etc. *

What time do you eat breakfast? *

What do you eat for breakfast? *

What time do you eat lunch? *

What do you eat for lunch? *

What time do you eat dinner? *

What do you eat for dinner? *

What time do you eat snacks? *

What do you eat for snacks *

My hunger is *

After meals I feel *

I go to sleep at... *

My sleep quality is *

I sleep deeply through the night I have trouble falling asleep I wake up during the night 1 or more times I have restless sleep with lots of dreams Other / Varied

I wake up at... *

When I wake up I feel... *

Ready for the day and enthusiastic! Still tired and I don't want to get up In physical pain / aches Like I want to happily day dream in bed for awhile Other / Varied

Click all that apply

Please describe bowel movements - number per day and time of day of occurance - more detailed questions follow *

My bowel movements are *

Feel complete Feel incomplete Well formed, like a banana Hard and dry like pebbles or deer poop Loose and unformed Sticky and oily like peanut butter Brown Dark brown Yellow White Floats Sinks Odorous / sour / pungent Undigested food particles All over the place, I could say yes to most of these!

Poop is important! You might want to pay attention to it for a few days before answering these questions!

If possible, please include a photo of you! *

Max file size: 20MB

Please share your birth info - date, exact time and location, or if unavailable, your age *

If you have this information, please share! We will use it to look at your vedic astrology chart and determine more details about your health and constitution

Current Medications, Herbs, Supplements taking *

I have a physical disability or mobility impairment. *

Yes No

If yes to above, please explain and include any aids you use to support you in your day to day life. *

I have a history of, or current diagnosis of a mental illness, psychiatric disorder, or psychiatric disability. *

Yes No

If yes to the above question, please explain and include any aids you use to support you in your day to day life. *

Anything else I should know? *

How did you hear about Kaya? *

I am a client or student of Kaya's already Internet Search Facebook Friend Instagram Practitioner referal Other

If Other please specify: *

I have answered the above questions truthfully and understand that my health status is confidential. I am aware that Kaya will only work within her scope of practice and in some cases may need to refer clients and students who have needs outside of her area of expertise. {Please fill in your full name below} *

Fill in your name. You will be given an additional release form to sign.

Submit

Kaya is the founder of SRY™ which is based in the full spectrum of the Vedic yoga tradition. She has been teaching therapeutic restorative yoga therapy since 2001. Kaya's work is healing, transformative, deeply rejuvenating and empowers her student and clients with wisdom and inner experience. Her trained in the full spectrum of the Vedic Tradition includes Yoga, Yoga Therapy, Prenatal Yoga, Ayurveda, Women's Health, Eastern Anatomy, Sanskrit, Vedic Astrology and Vedanta Philosophy. She collaborates with her husband Michael Manzella, a Vedic Astrologer, to serve yoga students and teachers who are inclined toward depth of inner experience and knowledge. MORE ON KAYA

About
SRY
Ayurveda
Work with Me
Audio
Contact
- Resources