Thank you for being a part of our Wellness Haven Family! As you are already aware, it is not just a Yoga Studio but a Health Center!

We appreciate your patience in filling your information. Even though you have been at Wellness Haven and enjoying its health benefits, we would like to get to know you better and evaluate your health progress so that you can maximize your health benefits. Our Existing Student Health Evaluation process is as follows: 1. This online form submission 2. Scheduling an appointment for evaluation of your health, so that we can communicate on your health progress..
Wellness Haven website: http://wellnesshaven.yourcoachsite.com/
Wellness Haven Weekly Calendar and Holiday Schedule: http://wellnesshaven.yourcoachsite.com/announcement/
Wellness Haven New Student Information: http://wellnesshaven.yourcoachsite.com/new-students/
Wellness Haven Policies: http://wellnesshaven.yourcoachsite.com/policies/
Please also know that all external deals that we offer through external sites are ONLY for FIRST TIME STUDENTS of Wellness Haven, no matter what you see on the external sites. Please do not buy any external deal for yourself or your family members even if you have not been at our studio for extended periods of time, if you or your family member has already enjoyed our services. If there is any confusion, please do not hesitate to contact us. We introduce our services to you so that you can decide for yourself whether you want to continue being a part of our Wellness Haven Family. If you choose not to, we respect your decision and wish you health and happiness.

Are you enjoying your stay at Wellness Haven? What is it that you like about Wellness Haven? Please let us know for your feedback will help us make it even better.(required)

What else would you like to see at Wellness Haven? Which aspect of health would you like to see added that is not already a pat of our program? We would love to see what else we can do to improve the quality of programs at Wellness Haven. (required)

Are you comfortable with navigating our website? Are things clear? Are you able to find all our service offering like yoga, meditation and breathing, nutrition program, yoga retreat, workshops? Is the Wellness Haven Schedule/Calendar easy to find? Is it clear? Please do let us know any issues you face with our website. We want it to serve all your needs with ease. (required)

Let us know which type of Wellness Haven Yoga Program and Package you are enrolled in currently. (required)
1 week Unlimited Introductory Yoga Special2 weeks Unlimited Introductory Yoga SpecialAnnual Unlimited YogaMonthly Unlimited Yoga4 Yoga Classes8 Yoga Classes12 Yoga Classes with 3 Months Expiry Date12 Yoga Classes with no Expiry DateI am coming to Wellness Haven through an external deal

If you are coming to Wellness Haven through an external deal, which type of external deal is it? (required)
1 Yoga Class donation from Wellness Haven through School4 Yoga Classes donation from Wellness Haven through School1 Yoga Class donation through School6 Yoga Classes External Deal10 Yoga Classes External Deal20 Yoga Classes External Deal24 Yoga Classes External Deal30 Yoga Classes External Deal

Are you enrolled in '12 week Nutrition Course: Lower Your Fat Percentage'? (required)
YN

Are you enrolled in ' Meditation and Breathing Classes'? (required)
YN

If you came with an external deal or school donation, which company or school was it from? (required)

Contact Information

First name (required)

Last Name (required)

Gender and Adult or Child (required)
Female AdultMale AdultFemale ChildMale Child

Address (required)

City (required)

State (required)

Zip Code (required)

Email (required)

At least 1 phone number required

Cell Phone (required)

Home Phone (required if different from cell)

Work Phone

Birth Date, so that we can understand your health matters better (required)

Occupation, so that we can understand your stress level better (required)

Health Information

How often do you exercise? 5-7 days a week/ 4-5 days a week/ 2-3 days a week/ 1-2 days a week/ 1 day a week/ None (required)

What other type of exercise do you do besides yoga? Aerobics, Dancing, Zumba, Weight-lifting, Running/Jogging Walking or Just Yoga (required)

Where do you exercise besides Wellness Haven? 1. At a Gym - Name of the Gym 2. At a Yoga Studio - Name of the Yoga Studio 3. At Home on my own 4. At Home with a DVD or NA (required)

Are you regular with your annual health checkups - Yes or No? (required)

When was your last physical? (required)

Are you facing any physical injury? "Ankle" "Knee" "Lower Back" "Shoulder" "Hips" "Other" "None" (required)

Are you facing Mental Stress and/or Depression? Yes or No? (required)

If you are facing Mental Stress and/or Depression, what is the severity? (required)
LowLow-MediumMediumMedium-HighHigh

If you are facing Mental Stress and/or Depression, what is the reason? (required)
Home RelatedWork RelatedBoth Home and Work Related

If you are facing Mental Stress and/or Depression, would you like to elaborate? (required)

If other health issues, please describe them or NA

If you are facing injury or other physical or mental issues, have you consulted your doctor for doing yoga and/or meditation and breathing techniques and/or Wellness Haven Nutrition Program? Please note that if you are in pain but have been doctor recommended to do yoga, our Yoga Clinic is the class to be in, but if you need personal attention, you need private one on one Yoga Therapy, and not a group class. Our Beginner Yoga class is for those who can handle a flow based class. Please do consult your doctor if you are in any kind of pain or are facing injury before you sign up for a class. (required)

Please check Wellness Haven Schedule under the Announcement tab at our website and let us know when - Date and Time - you would like to schedule your Health Evaluation appointment.

If you are in our yoga program, what type of classes do you like? List one or all:
1. Slow paced 2. Fast paced 3. Mixture of Slow and Fast paced 4. Flow Style 5. Holding Poses 6. Mixture of Flow and Holding Poses 7. All the above (required)

Which yoga classes do you currently attend at Wellness Haven? Here is an explanation of our Yoga Classes:
Yoga Clinic - For those who want to learn the basics of Yoga Postures and Alignment and for those who may not be ready for a Flow Yoga Practice

Beginner Slow Flow Yoga - For those who like a slow, flow based practice without the difficult poses

All Levels Beginner to Advanced Flow Yoga - For those who enjoy being challenged no matter what the state of the body!(required)

Yoga ClinicBeginner Slow Flow YogaAll Levels - Beginner to Advanced YogaYoga Clinic and Beginner Slow Flow YogaBeginner Slow Flow Yoga and All Levels Beginner to Advanced Flow YogaI attend whichever time suits me irrespective of the class

Date you'd like to sign-up for evaluation

Time you'd like to sign-up for evaluation. Please check Wellness Haven Schedule under announcements tab first, ensuring it is not a holiday.

What are you hoping to achieve at Wellness Haven – a Health Centre, not just a Yoga studio!!?(required)
Yoga Postures for the physical aspects of yogaMeditation and Breathing for the mental aspects of yoga12 Week Nutrition Course and Accountability Coaching for the Nutritional aspects of yogaMassage for WomenRehab one on one yoga therapyBoth Yoga and Meditation & BreathingAll 3 aspects: Yoga Postures, Meditation & Breathing, Nutrition

Emergency Contact Info Info for your own safety

Emergency Contact Name (required)

Relationship (required)

Phone# (required)

Do you consent to get yourself photographed/video taped in group pictures?
YesNo

Would you refer us to your family and friends?
YesNoI am still figuring out the Wellness Haven Program

We would really appreciate it if you would care to write a testimonial for us - Wellness Haven Services and Umang as a Service Provider/Instructor

Thank you for your support, testimonial, and your being a part of our Wellness Haven Family. We could not have made it without your support. Please do come by and talk with Umang anytime you have a question or a suggestion for making things better. We truly care about your health and want to do everything to improve the quality of our services to you.

Release of Liability:

In signing below I agree that Wellness Haven LLC , the Instructor & the Facility are in no way responsible for the safekeeping of my personal belongings while I attend class. I understand that the class conducted at Wellness Haven, LLC may be physically strenuous and I voluntarily participate in them with full knowledge that there is risk of personal injury or death. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against Wellness Haven, LLC, the Instructor & the Facility for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise.

*Please read the above and sign below with your full name and the date:

***We reserve the right to refuse service