The Wellness Hub Client screening Form

Name*

First NameLast Name

Phone Number*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

In Case of Emergency Contact- Name and Number*

Do you have any specific dietary requirements? *

YesNo

If yes, please provide details *

YesNo

If yes please please provide details?*

Do you have any current injuries, movement limitations or health conditions? If yes please give details. *

Please answer the following *

Rows	Yes	No
Has your doctor ever said that you have a heart condition (had a stroke, heart attack, heart condition) and/or should only do physical activity as recommended by a doctor
Do you feel any pain in your chest on physical exertion?
In the past month have you had any chest pain when doing physical activity?
Do you ever lose balance due to dizziness or do you ever lost consciousness?
Have you ever been told by a doctor that you have a bone, joint or muscular problem that could be made worse by physical activity?
Do you have a diagnosed illness that could be made worse by physical activity?
Is your doctor currently prescribing you medication for a heart condition or blood pressure?
Do you know of any other reason why you shouldn't do physical activity?
Are you pregnant or have given birth in the past 6 months?
Are you currently breast feeding?
Have you had any recent surgery (past 12 months)
Are you currently on any other medication?
Do you have a lung condition (ie asthma?)
Have you been diagnosed with a mental health condition?
Do you consider yourself to have low mood?/Any mental health concerns?

If you have answered YES to any of the following please give more details below*

Do you know of any reason why it may not be safe for you to participate in any of the retreat activities?*

Have you been advised by a GP in the past 12 months, that it is no safe to exercise?*

Please detail any medication you are currently taking?

Informed Consent

Sound Bath- This does not come with any specific contraindications, however, if you have epilepsy, or any other conditions that make you sensitive to sounds, or you feel you may be uncomfortable please make us aware before the event.

I agree that I have answered all questions to the best of my knowledge, and I affirm that I am fit and can participate in physical activity. If I have answered yes to any of the above questions or have any doubts that I am fit and well enough to take part in exercise, I will first consult with my doctor to get medical clearance. I acknowledge that participation is at my own pace and comfort level, and if anything feels too challenging I should discontinue the session.

I agree to use my judgment to determine a safe exertion level, and to stop any activity that feels outside my capabilities/limitations. I will not continue with any exercise that does not feel safe for me. I understand that by signing this agreement I waive and release The Wellness Hub with Laura and Jane in any way from liabilities and demands due to injury, loss, or adverse health conditions due to participation.

I have read and understand this document and wish to participate in fitness activities.

Please bring suitable footwear and clothing if you wish to join us for outdoor nature walks, and also make us aware of any physical limitations that may restrict you. If you require assistance in navigating the property due to physical limitations, please make us aware of this in advance so we can put the correct support in place.

By signing this form- You are also agreeing to our cancellation policy (please see below.

Further terms, conditions and policies for retreats home & away:

Your Health

It is your responsibility to let our teachers know if you have any injuries and to be mindful at all times of your own body’s capability during our retreats. If you experience any injury or discomfort during any activity during the retreat, then please stop participating immediately.

It is also your responsibility to consult a doctor with an understanding of fitness to check that you are sufficiently fit and healthy to undertake physical activities that you may choose to do whilst on the retreat.

Please advise us of any mental or physical health conditions and dietary requirements before you book. If you have health conditions and dietary requirements that may be affected by the activities offered on our retreats we reserve the right, for your own wellbeing, to advise you to stop participating.

Whilst all measures are taken to ensure a high standard of health and safety, our retreats do take places where the land is uneven and we shall not be responsible for any injuries caused by uneven terrain.

We ask that women who are 12 to 28 weeks pregnant provide a letter from their health practitioner specifying that they are fit to travel and able to engage in the activities that we provide.

Acknowledgement of risks

You warrant that You are aware that all exercise and travel carries risks, and acknowledge you are participating willingly, and in knowledge of these risks.

You recognise that We are not able to provide you with medical advice, and that any information provided should be used as a guideline only. If you have any prior knowledge of health concerns or health risks, you acknowledge that it is your responsibility to seek clearance from a health care professional prior to attending any of our retreats.

Indemnity

You agree to fully indemnify without limitation any trainer(s), director(s) or contractor(s) against any injury, malpractice, mishap, or accident during any and all interactions with the Company away from, or at the primary place of business for our retreat style learning experience.

Payment Policy

A non-refundable booking fee of £100 per person is required upon booking. Payment of any outstanding sums owed (the balance) must be made before the specified Payment Due Date (21st April 2025) for the Retreat which you are booking. Prices DO NOT include flights, transfers or travel insurance.

Travel Insurance & Cancellation Policies

We recommend that your travel insurance covers the activity of your retreat with us as well as unexpected cancellation, sickness, losses and all the usual risks. Note: Refunds are not permitted after the payment due date, hence this recommendation, also, it is your responsibility to organise suitable travel and health insurance. You acknowledge that Jane Macdonald or Laura Moyes are not in the business of providing insurance products and cannot be held liable if your failure to arrange suitable insurance coverage leaves you exposed, medically, financially or otherwise.

You understand and acknowledge that it is a condition of booking that you must take out an adequate travel insurance policy that covers all items listed in the sample itinerary for your chosen Retreat, as well as but not limited to, trip cancellation insurance, and any other activities that which may reasonably be undertaken during the course of your Retreat. The policy and insurance coverage must be valid and in effect for the entire duration of your Retreat.

Please note, even if you have private health insurance in your Country of Residence, it is unlikely that this insurance will cover overseas trips to the extent required to participate in the activities organised on your trip.

You will be asked to email or bring your policy with you to the retreat in case of an emergency.

Cancellations Policy: Guest Cancellations

If you need to cancel this retreat fees will apply. Any notice of cancellation must be provided in writing.

Please refer to the following for a breakdown of applicable cancellation fees:

If you cancel 90 days or more before your Start Date, you will be refunded the full amount paid up to that date for your retreat. This excludes the £100 deposit per person which is non-refundable. If any cancellation is made in the 28 days prior to your trip, there will be no refund. This is in alignment with standard policies to cover host costs incurred to date, re-advertising costs and other expenses, in addition to potentially being unable to fill the space due to short notice.

If you have booked the additional uplevel package (90mins of 121 time- with Jane and Laura) please give a description of what areas of your health/wellbeing you would like to work on?

What is the main thing you would like to gain, from coming to the retreat?

YesNo

Date *

Date

Signature of Participant *

Client screening Form

Basic Info

Health and Fitness Screening