Health Questionnaire – General

Please answer the following questions as thoroughly and comfortably as you can, as your responses play a vital role in tailoring our approach to your individual needs.

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Name

First

Last

Mobile number

Emergency contact name

Emergency Contact number

What has drawn you to this course/event?

Have you any previous meditation experience?

Some practices involve gentle movement. Do you have any physical conditions that might make sitting, standing, walking, or doing gentle stretches difficult?

What are the current stressors in your life?

Do you have any traumatic past events, which are affecting your sleep or how you function during the day? eg nightmares or flashbacks

Is there anything from your medical history, including mental health, which would be helpful for us to know (eg panic attacks, PTSD, anxiety, depression, psychosis etc)

Are you currently seeing a therapist, counselor, psychiatrist or mental health worker? Have you discussed doing this course with them?

Have you experienced any bereavement, divorce or other significant events in past year?

Disclaimer

I have read and understood this statement *

This course/event is aimed at supporting your resilience and well-being, amid the inevitable challenges that life brings.

The evidence base for the benefits of mindfulness and self-compassion is extensive. We are, however, unable to give guarantees as to how the training will impact you, as this is dependent on so many factors.

We do however commit to offer you kindness and support throughout, whilst you remain responsible for your own well-being.

In some circumstances it may not be advisable to engage in training at a particular time in your life (eg in the midst of major upheaval, recent significant bereavement or trauma, or if you are currently living with a significant mental health problem).

If on receipt of your application any of these seems to apply, we will contact you to discuss. In the event that attending the course/event might not be advisable, a full refund of any monies paid would of course be made.

We are always happy to discuss if you are unsure whether to apply or have any particular queries before doing so.

Health Checkbox

I confirm that I am in good enough health to undertake this course/event *

I confirm that I understand that if I have any concerns about my suitability for the course I am able to consult a medical practitioner (such as my GP) prior to undertaking this course. I understand that if for any reason I am unable, or I think it unwise to engage in any of the guided meditations, or exercises, I am under no obligation to do so.

T&C checkbox

I have read and accept these terms and conditions *

I understand that if for any reason I am unable to undertake the course, a refund is available up to 4 weeks before the course starts less a £25 admin fee. For any withdrawal from the course later than 4 weeks before the course starts, refunds are entirely discretionary. Once the course has started no refunds will be given.

I understand that the personal information I have provided on this form to Claire Garthwaite is for a course/event/training in mindfulness/self-compassion, for which I have enrolled. I recognize that Claire Garthwaite will process personal information for those purposes (which is the lawful basis Claire Garthwaite will rely on for processing my personal information). I understand too that my data will be shared with any other teacher, who is co-leading, but not with others, unless any of the teachers reasonably believe that I may be at risk of harm to myself or others, or there is a legal duty of disclosure.

I understand that a record of my attendance will be kept for an appropriate period in accordance with professional regulatory and insurance requirements (and that that period is currently up to five years) and that Claire Garthwaite will take steps to ensure the accuracy and security of the record.

I also understand that I have certain other rights under data protection legislation which include the right to ask for my data to be erased (which I realize is subject to the teachers’ professional and insurance-driven need to retain data for a period), the right to get my data corrected, the right to make a complaint and the right to make a subject access data request.

I understand that if I have any concerns or queries about the use of my personal information or wish to exercise any of my data protection rights then I can contact [email protected] and that I can complain to the Information Commissioner’s Office if I am unhappy with how Claire Garthwaite has used my data and that the Information Commissioner’s address is: Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9 5AF. Helpline number: 0303 123 1113 www.ico.org.uk