Yoga Therapy for Wellbeing Registration Form

Yoga Therapy for Wellbeing

Eight week course registration form
Welcome. This registration form is for our Yoga Therapy for wellbeing eight-week course. The form asks a series of questions that will help us to ensure that we are creating a supportive environment for all concerned. Please take the time to address each of the following questions to the best of your ability.
Which dates would you like to book for? *

Full Name*

First NameSurname
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityCounty

Postal Code
E-mail*

Confirmation Emailexample@example.com
Phone Number*

Country CodePhone Number

Health History
Please say why you want to do the course*
Have you ever been diagnosed with a neurodevelopmental condition?*
Please also indicate current diagnoses
Have you ever suffered from depression, anxiety, or both? *
Have you ever been diagnosed with a mental health or psychiatric condition?*
Please also indicate current diagnoses
Are you currently taking any psychiatric medications, e.g., anti-depressants, anti-psychotics, medication for anxiety medication, etc.? Please list all current medications including purpose and dosage.*
Do you currently have a medical condition? Please list all current medical conditions, including asthma, emphysema, anemia, etc. *
Please also indicate current diagnoses
Do you have any physical injuries? *
Please describe recent drug use
Do you take any narcotics or recreational drugs of any kind, including alcohol, cannabis, etc.?
Please describe recent drug use

Starting Point
Have you practiced meditation or mindfulness practices before?*
Please describe recent drug use
Have you ever done any yoga or movement practices before? If so, can you share a bit about them?*
Please describe recent drug use

Payment Terms

Derbyshire Mind fully funds the Yoga Therapy for Wellbeing course. Please be aware that there are limited spaces available. If you reserve a place and do not show up, someone else may miss out on the chance to have the experience. In addition, it would ordinarily cost £160 for the eight weeks. We ask that you commit to the full course if you take a place.
Further Information

The course is run by Shaura, one of the founders of Integration Psychotherapy Services CIC (IPS). Our initiative is also based in Eyam Hall Courtyard and offers subsided psychotherapy to the local and online community. Integration Psychotherapy® is part of a new wave of therapy that brings together mind, body and spirit in the therapeutic space.

Head over to this page if you want to explore face-to-face or online psychotherapy.
Terms & Conditions

By signing and submitting this form, you are agreeing to the following terms and conditions:
- I understand that therapy with Shaura may involve physical movement, breathing and meditation. I represent that to the best of my knowledge and belief I am able to participate in these aforementioned activities; in the event that I become unsure of my ability to participate in these activities I understand that I am liable for speaking with a GP or a healthcare professional of my choice to receive further counsel on how I should proceed.
- I understand that I am responsible for disclosing any concerns I may have about specific movements, meditations, or breathing exercises during my sessions with Shaura. I also recognise that I am responsible for explicating my medical and psychiatric history in so far as it may impact upon my needs in therapy with Shaura. I understand that Shaura Hall is not a medical professional and in the unlikely event that I incur injury during or as a result of my activities in therapy with Shaura, I will not hold Shaura Hall liable and hereby accept full responsibility for myself at all times.
- I have read and understood all of the information provided in this document. I also understand that by signing this contract, I am assuming full responsibility for any and all consequences of breaching the terms and conditions set forth here.
Certify & Submit
I, First Name* Last Name* , hereby confirm that the information I have disclosed in this document is accurate to the best of my knowledge and belief.

By signing below I am also agreeing that I have understood the information outlined in this document and agree to adhere to the above-listed terms and conditions.
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Date*

MonthDayYear
Date
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Yoga Therapy for Wellbeing

Health History

Starting Point

Payment Terms

Further Information

Terms & Conditions

Certify & Submit