Private Yoga on Long Island Presents...

Name *

First Name

Last Name

Phone *

(###)

###

####

Are you inquiring for yourself or someone else? *

Myself

Someone else

Have you been referred by someone? *

Yes

No

What are your goals/expectations for enrolling in the Ageless Yoga Program? (choose all that apply) *

Increase strength/bone density

Reduce muscle/joint stiffness

Increase flexibility

Better balance

Preventing signs of aging

Pain reduction

Injury rehab

Balance Hormones

Addressing a specific health concern

Other

Not sure, this is for someone else!

Have you (or inquired) practiced yoga before? *

Yes

No

Not sure

If yes to above question, how often do you practice?

Daily

Couple of times a month

Not very often

Tried it once

What styles of movement have you practiced in the past or currently? (choose all that apply)

Hatha

Vinyasa

Yin

Restorative

Iyengar

Bikram

Power

Ashtanga

Kundalini

How would you rate your (or inquired) current level of activity? (NO JUDGEMENT!) *

Sedentary/inactive

Somewhat active

Average

Somewhat active

Extremely active

I choose not to respond

Not sure

Which package are you interested in? *

$397/month (1 session per week)

$597/month (up to 2 sessions per week)

Select all that apply - When were you looking to have your (or inquired) sessions? (we are open Tuesday through Saturday only) *

Weekday mornings

Weekday afternoons

Weekday evenings

Saturday morning

Saturday afternoon

I have a pretty open schedule

Regarding the person I am inquiring for, I am not aware of their schedule

Please read and agree to these terms before submitting: I acknowledge that this program is operating on a monthly billing basis. As stated in the Q&A section on the homepage, you may rollover any missed sessions into a “bank” to be used at a later date. Accumulated sessions expire and are non-refundable 30 days after you cancel your membership. *

Acknowledged