Consultation Form

Name

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Address

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City

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Zip Code

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State

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Country

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Home Phone

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Wk/Cel

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E-mail(*)

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Birth Date (ex: 01/01/1970)

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Birth Time (10:00) AM

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Birth City

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Birth State

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Birth Country

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Age of Physical Body

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Weight

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Height

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High School

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College

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Graduate

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Referred By

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Physician

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Reason for Your Consultation/ Please number each reason in order of importance

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Specific Areas of the Body with Issues

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Childhood Diseases

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Medications/Supplements

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Do you have any addictions to Coffee, Black Tea, or Cigarettes or Drugs?

Yes
No Invalid Input

If Yes, how often, and for how long has this been a habit?

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List any genetic or hereditary diseases from specific family members

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Do any family members have addiction problems (e.g., alcohol, drugs)? If yes, who?

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Did you experience any emotional abuse in your life?

Physical
Mental
Emotional Invalid Input

Family/Social life

Good
Average
Not good Invalid Input

Current Career/Job

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Career/Job satisfaction

Love it
Ok/Temporary
Unhappy Invalid Input

What time do you usually go to sleep?

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What time do you usually wake up?

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Sleep

A. Poor, interrupted, light, sensitive, restless, difficulty falling asleep
B. Variable, little at times but sound, fall asleep quickly but eager to rise
C. Heavy, deep, excessive at times, can be difficult to get up Invalid Input

If your sleep is interrupted, what time do you wake up at night?

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Dreams

A. Frequent, flying, running, moving, fearful
B. Moderate and occasionally colorful, anger, violent, dramatic
C. Infrequent, watery, romantic, loving and friendly Invalid Input

State of Mind

A. Restless, active thinker, lack focus and attention, poor concentration
B. Aggressive, intelligent, sharp, focused, intervals of intense thoughts
C. Calm, slow thinker and quite relaxed, steady and even-minded Invalid Input

Memory

A. Quick, recent, short term, absent minded, forgetful and then reminded
B. Sharp, clear, vivid and detailed, retained then lost, grasping
C. Slow but steady, longterm, sound and clear Invalid Input

Is your life spiritual? Explain:

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Faith

A. Erratic, changeable, many beliefs, unsure, questioning
B. Strong, overwhelming, determined, intrigued and curious
C. Steady, loyal, hesitant to change Invalid Input

Emotional Temperament

A. Nervous, fearful, erratic, mood swings
B. Aggressive, irritable, jealous, motivated
C. Calm, conservative, attached Invalid Input

Is your life purposeful? (Goals, direction)

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How often do you practice any type of yoga and ayurveda (postures, breathing, mantra disciplines, meditation, service to others, contemplative hiking, gardening or nature dwelling)?

Daily
Weekly
Monthly
Never Invalid Input

Any additional thoughts or comments you feel will be supportive to this consultation

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Payment Policy

I acknowledge and am confirming that my payments towards this event, course, program or consultation or any service offered by Dancing Shiva or Mas Vidal and all associated faculty are entirely non-refundable. This includes personal reasons or circumstances that I may experience during the timing of the course, program or service is being offered to me.
I acknowledge that Dancing Shiva and Mas Vidal are not responsible for my personal issues, behavior or opinions that may result during my participation.
When making a payment, I have authorized Dancing Shiva and Mas Vidal to charge my credit card for the purchases listed on the Dancing Shiva website, in program catalogs or as arranged directly via Dancing Shiva staff by phone and or email.

Liability Release

YOU ACKNOWLEDGE THAT BY SIGNING THIS FORM AND/OR PARTICIPATING IN ANY ACTIVITIES OR THERAPIES AT DANCING SHIVA YOGA AND AYURVEDA, CASA TEJAS OR ITS AFFILIATE LOCATIONS YOU HAVE CAREFULLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. YOU ACKNOWLEDGE THAT YOU ARE AGREEING TO WAIVE ANY RIGHT THAT YOU MAY HAVE TO BRING A LEGAL ACTION TO ASSERT A CLAIM AGAINST DANCING SHIVA YOGA AND AYURVEDA OR MAS VIDAL.

Yoga or Ayurveda are no substitute for medical care and offers no health warranties or guarantees of any kind. Always consult a physician before starting any yoga or exercise program.

By choosing to attend events, programs, retreats, classes, consultations, and/or any Ayurvedic therapies or detox programs at Dancing Shiva Yoga and Ayurveda, Casa Tejas or any of its affiliate locations, you agree that if you engage in any physical exercise, activity, use any Dancing Shiva Yoga studio facility, or take any Dancing Shiva Yoga and Ayurveda course or treatment, you do so at your own risk. This includes, without limitation, your use of Casa Tejas its dressing room, bathrooms, swimming pool, hot tub, steam room, showers, parking area, sidewalk, hallway, balconies, stairwell, yoga room, treatment rooms or any equipment used in the studio or in therapies. This also includes your participation in any activity, class program, treatment, or instruction. You agree that you assume all risk of injury, illness, damage or loss to you or your property that might result, including, without limitation, any loss or theft of any personal property. You agree on behalf of yourself (and your personal representatives, heirs, executors, administrators, agents and assigns), to the maximum extent permitted by applicable law, to release and discharge us (and our affiliates, employees, agents, representatives, successors and assigns) from any and all claims or causes of action (known and unknown) arising out of your or our acts or omissions, including negligence.

This waiver and release of liability includes, without limitation, injuries which may occur as a result of
a) your use of any equipment or facilities,
b) any instruction or supervision received while at a Dancing Shiva Yoga and Ayurveda sponsored event, on the Casa Tejas premises, in classes or private sessions with Mas Vidal /or
c) your slipping and falling during an event or on the Casa Tejas premises or wherever Dancing Shiva is hosting its courses, programs or retreats.

I accept the and understand the policies of the Yoga & Ayurveda Program(*)

Yes

Please accept the terms and conditions

Please use the signature box below to draw in your signature. By signing this box you agree to the terms of the payment policy.(*)

Sign Above

Please sign the form

Note: Both you and Dancing Shiva will be emailed a PDF file with the above payment policy and your signature from this form on it. This is considered a binding contract between you and Dancing Shiva.

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