Pre Meditation Questionnaire | Stacey Grey Yoga

First name

Last name

Address (Please only complete this if you are attending online/Zoom sessions)

Birthday

Day

Month

Year

Email

Phone

Are you currently Meditating?

Yes

No

Have you Meditated before?

Yes

No

Do you have high/low blood pressure?

Yes

No

If you have ticked yes to any of the above, please could you give more details here:

Are you currently taking any medication, if so, please give details below:

If you tick "yes" to any of the following contra-indications please either provide a letter from your mental health team/health care provider or alternatively sign the declaration below to confirm you have verbal consent from your mental health provider

Clinical Depression

Bipolar

Epilepsy

Schizoprenia

Do you currently have any physical, medical, mental or emotional conditions that can be adversely affected by me teaching you how to Meditate or by taking part in Meditation sessions? If so, please give details.If you are not sure, please discuss with me.

Emergency Contact Name

Emergency Contact Phone Number

By participating in these sessions, I understand and acknowledge that Meditation may involve emotional, physical or psycological responses. If I experience discomfort or distress during the session, I will stop and inform Stacey Grey or my healthcare professional. Stacey Grey disclaims all liability directly or indirectly for any injury, loss or damage incurred with initiating a new Meditation program or during sessions. I agree to take full responsibility for my wellbeing during and after each session. I understand and accept these risks. I declare I have made my mental health/health care provider aware that I am attending Meditation sessions and I agree that I will notify my mental health team/health care provider should my health or symptoms change during these sessions.

Signature

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Date

Day

Month

Year

GDPR Regulations.

In order to comply with the GDPR regulations can you please tick the boxes below?

I agree for you to store my data, for the period laid down by your insurance. I understand that this data will be stored securely and I have a right to withdraw this content at any time.

Yes

I agree for you to use my data so that you can provide me with information about any future courses etc that you may be running.

Yes

STACEY GREY

Yoga, Meditation & Pilates

Pre-Meditation Questionnaire