Yoga for Wellbeing Booking Form

This form is designed to give us information about your physical and mental health so we can assess whether this course is suitable for you. It also helps to ensure that we can provide you with the safest and most enjoyable yoga practice. Everything you share with us will be completely confidential. If you feel unable to answer any questions don’t worry, we can discuss them further if needed.

First name

Last name

Address

Phone

Birthday

Day

Month

Year

Emergency contact (name, relationship and phone number)

Are you experiencing one or more of the following. If the answer to any of the below is yes, please state how much this affects you on a scale of 1 to 10, 1 being not much at all and 10 being greatly affects you:

stress

anxiety

low mood/ depression

Isolation

Loneliness

Low Confidence

Lack of purpose

Other, please tell us more

Do you have any experience of yoga, meditation or mindfulness?

Have you been diagnosed with any mental health conditions? If so please describe:

Do you have any current chronic health conditions, injuries, musculoskeletal issues or areas of limited mobility/pain or are you dealing with any other physical health concern? If so please describe:

Are you currently on any medications (prescribed or bought over the counter including herbal and other supplements)? Do you experience any side-effects?

What is your current work status? (Full time employed, part time employed, self-employed full or part time, not working)

What would you like to gain from these sessions?

Is there anything else you would like to share?

How did you hear about this course?

Thank you for sharing. We will get back to you with in the next few days to let you know if you are eligible for a place on the course. All your information is stored securely and inline with GDPR recommendations. Please press submit to complete this form.

Yoga for Wellbeing Booking Form

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