Mindfulness Retreat Form

INFORMATION AND DISCLAIMER FORM – Strictly confidential

The information you supply will be treated in strict confidence. The information is kept securely and will not be shared with anyone.

Name(Required)

Prefix First Last

Email(Required)

Phone number(Required)

Address(Required)

Postcode(Required)

Profession

Mailing list(Required)

Would you like to be added to our mailing list for future events? You can unsubscribe at any time.

Yes

Emergency contact

Name and phone number of someone we can contact in case of an emergency

Medication

Are you currently taking any medication - please state the name of medication and reason for taking it

Other requirements

Any special requirements, learning needs or medical conditions you feel we need to know about

Reason for joining(Required)

Please share with me your reasons for wanting to do mindfulness

Experience(Required)

What experience do you have of mindfulness?

Physical conditions

Some practices involve gentle movement and stretches. Do you have any physical conditions that you think I need to be aware of?

Mental health

Have you had any mental health difficulties within the last few years such as anxiety or depression?

Life events

Have you had any distressing live events in the last year, or is there anything going on in your life now that you would like me to be aware of?

Source

Where did you hear about our mindfulness sessions?

Photo and video consent(Required)

I will be taking some photos during the day and recording some video for marketing purposes, please indicate below whether you are happy for me to include you in these. All shots and footage will be done sensitively and not during meditations.

Yes

AFTERCARE ADVICE:

Doing mindfulness offers an opportunity for change and this can be challenging at times. I am here to support your learning, however I encourage you to also have your own support system in place, and at the same time take care of yourself. If you have a friend, counsellor, therapist, it is a good idea to discuss anything that comes up for you with them. I am not a trained counsellor and I am restricted to the limits of my training.

Tel: 07793 532911

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INFORMATION AND DISCLAIMER FORM – Strictly confidential

AFTERCARE ADVICE:

Telephone: 07793 532911