Name *

First Name

Last Name

Do you suffer from any condition that may affect your physical ability to spend the best part of a day sitting? *

If so please detail any special requirements or adaptations that can be made to help you.

Yes (please give details below)

No

Have you experienced or been diagnosed with any mental health issues (including anxiety/depression) at any point? *

Yes (please give details below - don't worry most people have!)

No

Do you wish to engage in a gentle "yin" yoga practice *

Please know that you can also decide on the day but this just gives us an idea of numbers

Yes

No

Not sure!

Have you experienced any major trauma in your personal life over the last 2 years? (eg Death/Divorce/Major Injury) *

Yes

No

Is there anything else you feel it would be helpful for Kate or Ursula to know?

Yes (please give details below)

No

I understand that Kate or Ursula may contact me to discuss the above prior to the retreat. *

For you to attend the retreat day it is important that we are completely confident that it won't jeopardise your emotional or physical wellbeing. We'd appreciate your consent to get in touch prior to the retreat if necessary. If so it will be Kate that contacts you about emotional and physical issues affecting the mindfulness and Ursula about physical issues that may affect the yoga.

Yes I give my consent to be contacted

No I do not wish to be contacted (please note that if the issues are of concern this may mean that you are unable to attend)

My preferred contact method is *

Mobile Phone

Email