Date *

MM

DD

YYYY

Name *

First Name

Last Name

Birthdate

MM

DD

YYYY

Phone Number

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you ever done any form of personal training? *

Yes

No

Have you ever worked privately with a Pilates or Yoga instructor? *

Yes

No

Has your doctor cleared you for exercise?

Yes

No

Do you currently participate in a regular exercise program? *

Yes

No

Do any of the following ailments interfere with your daily life, either currently or in the past?

Lower back pain

Pelvic Pain

Any spinal or orthopaedic condition

Migraines

Heart problems

High or low blood pressure

Epilepsy (Grand Mal Seizures)

Digestion problems

Blood pressure (high or low)

Numbness or tingling

Anxiety

Depression

Other

Are you pregnant? *

Yes

No

If yes, how many weeks along are you today?

MM

DD

YYYY

Do you have children?

Yes

No

If you have given birth, how were your children delivered?

EFM

Intravenous fluids

Induction

Pitocin

Epidural

Cetheter

Vacuum extractor

Forceps

Tearing

Episiotomy

Cesarean Section

VBAC

Other

Do you engage in regular self-care practices (i.e., do you tend to your physical and emotional needs on a consistent basis)? *

Yes

No

Do you follow any specific dietary intake plan?

Yes

No

How high is the level of stress in your life, in general? *

High

Moderate

Low

Have you had to modify your routines due to your current condition?

Yes

No

Liability Waiver *

SERVICES PROVIDED All HomeBody lessons and classes will be facilitated by Amy Baumgarten. The intention of all lessons and classes is to cultivate physical wellness through somatic movement forms, including but not limited to pilates, yoga, Body Mind Centering®, dance, embodied anatomy, & hands-on bodywork. Amy is not trained in the medical field and is not a substitute for your physician or physical therapist. Her services are both rehabilitative and preventative in nature and will support your medical needs.  ENVIRONMENT PROVIDED Amy will meet you at a previously agreed upon setting — either Amy’s studio or your home.  For studio lessons, you may arrive a few minutes early to change clothes and settle into the space.  For home lessons, please allow a 5 minute window of flexibility to the scheduled start time, as transportation times may vary for Amy. RECOMMENDED ATTIRE Please wear comfortable clothing you can move in. Form-fitted articles are not required, but consider clothing that doesn’t hinder your full range of motion. Socks are welcome but not required. Bring an extra layer, in case the studio is chilly. CANCELLATION POLICY Due to the nature of personal fitness instruction, it is imperative that Amy receive 24 hours’ notice in order to cancel a scheduled appointment without charging your individual session or series. This policy gives you an incentive to maintain your commitment to your wellness practice. It also supports Amy’s ability to maintain a full and organized schedule. Any appointments cancelled within 24 hours will be asked to pay in full for services requested. To cancel or reschedule an appointment, go to www.homebody.acuityscheduling.com. PAYMENT Payment is due on or before a scheduled appointment. Payment may be made at the time of booking, or in person at the time of the appointment. If you have purchased a series (group of lessons), individual lessons will be automatically deducted. If payment is not received on or before the scheduled appointment, you will not be able to book another appointment until the balance is paid in full. Payment may be received in the form of cash, check, Venmo, and all major credit cards. All credit card payments incur a 3% convenience fee. Pre-Paid Series & Gift Certificates All purchases are final sale, and expiration dates apply. You will be informed of your unique expiration on date of purchase. Introductory offer (3 lessons) expires 6 weeks from purchase. Series of 4 lessons expires 60 days from purchase.  Series of 8 lessons expires 4 months from purchase. Gift certificates expire 1 year from purchase. ASSUMPTION OF RISK All information shared by Amy Baumgarten is based on her experiences, training, and professionally-derived opinions. Her training and knowledge are based on time-tested practices as well as her own collated research. Amy’s primary concern is to provide a safe environment for movement exploration. Nevertheless, all exercise inherently incurs some risk.  All new clients must sign a waiver that acknowledges the risks involved with this form of movement practice. All clients must fill out an intake form that depicts her or his movement background and wellness history. Please report any past or current injuries. This will allow Amy to make educated decisions about the movement choices best suited to your body and its history. Use of equipment also has its it inherent risks. Please do not use equipment without Amy’s guidance.  RELEASE OF LIABILITY In exchange for participation in the activities proposed by Amy Baumgarten and HOMEBODY, I agree to the following: 1. I volunteer to participate in a program designed for me by Amy Baumgarten and HOMEBODY. I waive possibility of personal damage which may be blamed upon such a program in the future and accept the responsibility for requesting such exercise. 2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in integrative movement coaching. I represent and warrant that I am physically and mentally fit and have no medical condition which would prevent my full participation in integrative movement coaching. 3. I agree to assume full responsibility for any risks, injuries, damages, known or unknown, which I might incur as a result of my participation in integrative movement coaching with Amy Baumgarten and HOMEBODY. I HAVE READ AND UNDERSTOOD THIS DOCUMENT. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS.

YES, I agree with all terms

NO, I do not agree

Would you like to receive occasional Moving Well tips from HomeBody? *

Yes

No