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NEW CLIENT FORM

Why we need the information and how it is used

 

• For insurance reasons, it is essential to know who attended the sessions

• To contact you about our services and new courses available

• To provide you with booking information

• For Internal and External Quality Assurance

Where do we store data?

• Data from this form related to the session is stored in a paper format in locked cabinets.

 

Who we share your data with?

• We do not share your data with anyone else. 

Please submit once completed

Personal Information

Personal Information

Name: 

Address:             

Town:

Postcode:                                                                                           

Telephone (home or mobile)

DOB:                                                                                             

Email:

 

 

Please tick this box if you would like to receive our monthly newsletter and occasional schedule updates

 

 

 

 

 

Please describe your past an present yoga/therapeutic movement practice:

Are you currently undertaking any form of regular exercise, if yes, please give details:

What do you hope to gain from yoga/therapeutic movement classes?

Describe your physical history, listing injuries, ailments, illnesses, surgeries, pregnancies and any other significant medical treatments.  Be specific about any areas of the body that were involved (e.g. right of left side of hte body.  Please also advise if you have had any issue with mental health including depression, periods of stress or anxiety.

Do you have any existing medical conditions?

Are you taking any medications?

If you answered yes to either of the above please provide details:

Are you currently a smoker or have quit in the past six months?

Next of Kin

Name/relationship

Telephone

Please tell us where you heard about us

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