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Why are you interested in private yoga? What goals or issues are you hoping to address? *

 
Describe your current yoga practice, if any.  (It's okay to be a beginner!) *

 
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Yoga & Ayurvedic Health Counseling Waiver, Statement of Understanding, and Policies

Ø  I understand that Tory J. Nash is a Yoga Teacher and Ayurvedic Health Counselor and educator who provides me with information on the Yogic and/or Ayurvedic approach to health and wellness, which may include postures, movement practices, diet, lifestyle, and/or herbal suggestions that may affect my health in a positive way. 
Ø  I understand that Tory J. Nash is not a medical doctor or a licensed medical practitioner, has not presented herself as such, and does not seek to diagnose, treat, or prescribe for disease, disorder, or other pathological conditions. 
Ø  Furthermore, I understand that Yoga and/or Ayurvedic Health Counseling is not a substitute for medical attention, examination, diagnosis, or treatment.  I understand that Tory J. Nash encourages regular medical checkups from a licensed medical professional of my choice, and that any medication that I am now taking upon my licensed physician’s advice, or will take in the future, is taken strictly according to my licensed physician’s directions.
Ø  Furthermore, I understand that only a licensed physician of my choice can advise me on medication dosages or the discontinuance or resumption of such medication.   
Ø  I understand that I may consult a licensed physician for any concern, at any time, about any disease or pathology that now exists or arises during my professional relationship with Tory J. Nash.   
Ø  I understand that Yoga includes physical movements.  As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated.    
Ø  I understand that Yoga is not recommended and/or not safe under certain medical conditions.  Furthermore, I affirm that I alone am responsible to decide whether to practice Yoga.   
Ø  I understand that as part of my Ayurvedic intake session, or any subsequent consultation sessions, I may be asked to answer questions or complete forms that disclose private health information (PHI).  I understand that these forms and the PHI they contain will be secured under HIPPA compliant procedures in a locked file cabinet and/or in a secure software program.   
Ø  I agree that I am interested in enhancing my own abilities to heal and establish health in mind and body, and this is the sole reason I have sought out these Yoga and/or Ayurvedic Health Counseling services.   
Ø  I understand that all Yoga and/or Ayurvedic Health Consultation sessions will adhere to the following policies:   
     o   All sessions require pre-payment in order to confirm appointment details. 
     o   Sessions will begin and end on time, no exceptions.   
     o   There is a firm 24 hour notice policy in effect if you need to cancel or reschedule your appointment.  If 24 hours’ notice is not provided to Tory J. Nash via email, the session fee will be forfeited in its entirety. 
     o   Individual sessions and packages of sessions are non-refundable. 
     o   Individual sessions and packages of sessions carry an expiration date that will be noted on the invoice and/or receipt.  After this expiration date, any unused sessions are forfeited in their entirety.  
     o   All communication regarding sessions is via email.   

By clicking "I Accept" below, which shall constitute my legal signature, I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against Tory J. Nash. I also acknowledge the above statements as fully read and understood.
     
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