Small Group Class Intake Form

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SRY
Ayurveda
Māyurveda
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Please fill this form out as a requirement to participate in a private group class with Kaya. This information will remain confidential. This allows me to ensure

that the course for which you are registered is appropriate for all participants attending
that I am fulfilling my ethical and legal obligation to work within my scope of practice
that I take on clients and students whom I can confidently help.

- Jennifer Mindlin, DBA Kaya Mindlin

If the form does not submit, please scroll back up and complete any incomplete required cells, highlighted in red.
Yes, this does work on a mobile device!
When you arrive for your training you will sign a release waiver.

Semi Private Yoga Class or Advanced Yoga Class Intake Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Please leave a cell phone if possible, in the case of cancellation or schedule changes.

Check all that apply *

High Blood Pressure (even if treated by medication) Pain that prevents me from "doing a day" without aid Pregnant Postpartum Low back pain Neck / Shoulder pain Headaches Migrains Anxiety Insomnia Depression Spinal disc problems Eating Disorder Vertigo PTSD Physical Disability or Mobility Impairment Panic Disorder or phobia {such as agoraphobia} Other mental illness or psychiatric disorder Other None of the above

Please elaborate on the above if needed, and share any other medical diagnoses, symptoms or discomforts. *

Do any of these apply to you? *

I have some normal physical / emotional pains but live a full, active life with few complaints I have some physical or mental pain but I am good at "pushing through" and live a pretty full life without the need of pain reducing aids {such as medication or other comfort measures for body or mind} My physical / mental pain is somewhat limiting and I can't do a "full day" without comfort measures or aids for my mental / physical pain. My physical / mental pain or diagnosis is very limiting in my day to day life, effecting my participation in community/relationships/work/sense of joy and purpose I am completely free from pain of any kind.

Experience in Deep Release, Spinal Release,e Svaroopa, Contemplative Practice or similar style of yoga. *

I attend group yoga classes I attend private yoga therapy sessions I attend workshops or retreats I am a yoga teacher in Spinal Release or similar style. I am new!

What in your life can support you in your healing process or yoga practice? (Supportive partner, family, lots of time, enough money to dedicate to myself, etc.) *

My name below signifies that everything above is true. *

Fill your name in below as a signature.

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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
Māyurveda
Work with Me
Audio
- Shavasana
- Bhagavad Gita Essentials
Contact
- Resources