4. Was our website clear? Did you find all information you were looking for? If you ran into any issues, please let us know what issue you faced. (required)
5. Please note that all introductory one time only offers are to introduce our services to those who have never experienced them before, so that they can find out if our services are suitable to their needs.
6. What attracted you to Wellness Haven? List all that apply. A: I want to experience Wellness Haven with an Introductory offering so that I can make an informed decision; B: Informative & Authentic Indian Values Based Services; C: Variety of Yoga Asana Classes to suit all needs; D: Gentle Yoga E: Bliss Yoga F: Breathing and Meditation Classes; G: Nutrition Program; H: Private Coaching; I: Yoga Retreat J: Yoga Teacher Training K: All of the above (required)
7. How did you hear about us? If you were referred by a Family member or a Friend, what is their name? We would like to thank them. (required)
Health Information
How often do you exercise? 5-7 days a week/ 4-5 days a week/ 3-4 days a week/ 2-3 days a week/ 1-2 days a week/ 1 day a week/ None (required)
What type of exercise do you do? Yoga, Pilates, Aerobics, Dancing, Zumba, Weight-lifting, Running/Jogging/ Walking/ NA (required)
Where do you exercise? 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 5. NA - I do not exercise (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" "Hips" "Lower Back" "Upper Back" "Shoulder" "Neck" "Elbows" "Wrist" "Other" "None" (required)
Are you facing Mental Stress and/or Depression?(required)
If you are facing Mental Stress and/or Depression, what is the severity? (required)
If you are facing Mental Stress and/or Depression, what is the reason? (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? Please note that if you are recovering from injuries, and have been doctor recommended to do yoga, our Gentle Yoga Class is the class to be in, but if you need personal attention, you need private one on one Yoga Therapy, that we also offer, 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. We reserve the right to refuse service for any reason. (required)
Voucher Info for students coming through external offerings (only if applicable)
Type of Voucher (Name of the company bought from):(required)
Voucher #:(required)
The name the voucher was bought under:(required)
The number below the barcode, if there is one:(required)
Pin code, if there is one:(required)
Number of classes bought:(required)
The day of your pre-scheduled 20-30 minutes evaluation appointment is considered your JOIN DATE, and EXPIRY of your term will be considered from this JOIN DATE. If you also attend a class the same day, the class will be counted as the 2nd class. Please make sure that you come in stretchy clothes for your appointment. Please check the Wellness Haven schedule at our website: http://www.wellnesshaven.com/class-schedule/ Also please wait for us to confirm your appointment before you come in. You are welcome to give us a call at: (925) 819-6327. Please wait outside for any yoga classes in session to end before walking in. Which day/time would you like to come in? :(required)
If you are already familiar with Yoga, what type of classes do you like? List one or all: Our Yoga Class Description is at: http://www.wellnesshaven.com/wellness-haven-yoga-classes/
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 8. I am not familiar with yoga and want to start with Gentle Yoga Class 9. I want to simply relax in the Bliss Yoga Class (required)
Many different health programs are offered at Wellness Haven. Please check our website for all details.
A. Yoga:
B. Meditation and Breathing
C. 12 Week Nutrition Program - Lower Your Fat Percentage
D. Private Yoga Coaching
E. Private Life or Business Coaching
F. Yoga Retreat
G. Yoga Teacher Training
If you are interested in any of our programs besides Yoga, please let us know:
What are your preferred yoga class times?
What are you hoping to achieve at Wellness Haven? Please list the conditions you may be facing. Through our various programs listed above, we offer relief from: Bad Posture, Stress, Anxiety, Depression, Headaches and Migraines, Sleeplessness, Lower Back Pain, Shoulder and Neck Pain, Sciatica, Hormonal issues, Thyroid issues, Arthritic Conditions, High Blood Pressure, High Body Fat, High Cholesterol, High Sugar Level,Tight Muscles, Acidity, and many other physiological problems. Always ask your doctor first. (required)
Emergency Contact 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 that we post on our website?
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 yoga 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 understand that participating in the wellness Haven Programs - Yoga, Nutrition, Meditation and Breathing, Private Coaching at Wellness Haven, LLC is my own decision and that results vary between individuals. I have read, understood and agree with the Wellness Haven Policies. 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:
***Please check your Spam if you do not receive a response from us.
***We reserve the right to refuse service for any reason
***All classes at Wellness Haven are non-refundable. The classes are also non-transferable, which means that classes cannot be shared between 2 people and/or you cannot apply the funds applied towards one program to another.
