1. Please fill out this form electronically

2. Save it as a PDF

3. Send it back to me via email

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If for some reason it is not possible to follow the steps above please either:

• Print it, fill it out, then Scan it and send it back to me via email

• Or print it, fill it out and mail it to me 

​

This information will be kept private and confidential.

Thanks for scheduling an appointment with me!

1. Please fill out this form electronically

2. Save it as a PDF

3. Send it back to me via email

​

If for some reason it is not possible to follow the steps above please either:

• Print it, fill it out, then Scan it and send it back to me via email

• Or print it, fill it out and mail it to me

​​

This information will be kept private and confidential.

If you are interested in learning what my role is as a Yoga Therapist, read the Scope of Practice published by the International Association of Yoga Therapists (IAYT).

I am a Certified Yoga Therapist recognized by the International Association of Yoga Therapists. If you are interested, read the Code of Ethics published in the IAYT website.

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