Access Support - Wellness Workouts Sign up

Access Support - The Wellness Workouts

A free course to support your physical & mental health
Participant's Name:*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Mobile Number:*
Email:*
example@example.com
Post Code:*
Ethnicity:*
Are you under mental health services?*
Do you have any additional needs or medical conditions that we should be aware of?*
Do you have any allergies?*
How did you hear about this programme? (Mental Health services, GP, Social prescribers, social media, organisation, self-referral etc)*
Emergency Contact

Who can we contact in an emergency?
Name*

First NameLast Name
Relationship to you*
Contact's Mobile Number*
Physical Activity Readiness Questionnaire

Becoming more active is safe for most people. However, some people should check with their doctor before they start becoming more physically active. The questions below will tell you whether you need to check with your doctor before beginning our sessions.

Please read the questions carefully and answer each one honestly. Tick yes or no*

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (e.g. bone, hip, or knee) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (e.g. water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

If needed, please expand below:
If you answered YES to one or more of the questions:

Talk with your doctor by phone or in person BEFORE you start becoming much more physically active. Tell your doctor about this form and to which questions you answered YES.

You may need to restrict your activities to those which are safe for you. Talk to your doctor about the kind of activities you wish to participate in and follow their advice.
IMPORTANT INFORMATION - read before taking part in our exercise sessions:
- It is important to listen carefully to the instructions given to you and follow advice given by the instructors/staff. You must notify staff if you are feeling unwell or do not understand instructions given.
- Whilst exercising, there is always a risk that accidents may happen and physical exertion can result in sprains and strains, feelings of dizziness or dehydration etc.
- If you are feeling pain, struggling with breathing or experience lightheadedness during an exercise session, please stop and inform the instructor.
- If you are not feeling well because of a temporary illness such as a cold or fever – wait until you feel better to attend the sessions.
- If your health circumstances change, thus changing your answers to the previous questions relating to health, you must seek medical advice before resuming exercise.
- Our staff will endeavour to create a safe environment for you to exercise in, however you do take part in our sessions at your own risk.
Health Care Questionnaires

These programmes are designed to support your mental health and wellbeing. We do a pre-project survey, mid-project survey and end-project survey to see the impact of the programme.

Patient Health Questionnaire (PHQ-2). Over the last two weeks, how often have you been bothered by the following problems?*

	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things?
Feeling down, depressed or hopeless?

General Anxiety Disorder 2 (GAD-2). Over the last two weeks, how often have you been bothered by the following problems?*

	Not at all	Several days	More than half the days	Nearly every day
Feeling nervous, anxious or on edge?
Not being able to stop or control worrying

IMPORTANT INFORMATION ABOUT BOUNDARIES - read before taking part in our sessions:

We all need boundaries. Boundaries keep us safe. Boundaries differentiate me from you. Boundaries help us focus on what is most important to us and boundaries improve relationships by creating clear expectations and responsibilities. Below are some boundaries we ask all of our participants to follow in our sessions:
- Attendance: The Wellness Workouts is a 10 session course and we ask you to attend all 10 sessions to receive the full benefits of the programme.
- Being in a group: group dynamics are vital to our work and it is important to remember that you are a part of a group, a piece of a bigger puzzle.
- Respect personal boundaries of other participants and staff, this may include proximity, touch or topics talked about etc.
- Be mindful of your tone, language and body language.
- Sharing: only share what you are comfortable with.
- Abilities: people may have different abilities to yourself and don’t just assume they can do everything you can do.
- Fairness & equality: you may not discriminate against people (staff and participants) on the grounds of:
- sex and gender,
- gender reassignment,
- sexual orientation,
- disability,
- race,
- religion & belief,
- age etc.
- Discrimination will lead to individual(s) being excluded from the programme.
- Timing: arrive on time, please notify staff if you are going to be late or absent.
- Wear appropriate and comfortable clothing for exercise.
- Talk to staff: If you feel uncomfortable or unhappy about your experiences within the group.
- Have an open mind and give all activities a try. Most importantly have fun & connect with others around you.
When boundaries are broken

If boundaries are crossed or blurred it can be unsettling for the group and can lead to the space feeling unsafe. If this happens, we will take immediate action:
1. Stage 1: a talk will be held between individual(s) and staff to discuss the issue and create clear steps to rectify it.
2. Stage 2: if boundaries continue to be broken an official warning will be issued.
3. Stage 3: if boundaries continue to be broken after stage 2, the individual(s) will be excluded from the programme going forward.
If you have any questions please do talk to staff, we are here to support you.
Acknowledgment
*The Positive Movement Project is the data controller for this project. All data received is subject to a duty of confidentiality. Statistical date will be shared where appropriate with the NHS, this is not considered personal data as you cannot be identified by it. This sharing of data allows for the evaluation of our services and the impact of it. All data will be appropriately deleted once the programme is complete.

Contact Kulraj on kulraj@thepositivemovementproject.org or 07497 853323 If you have any questions.

I have answered all of the questions correctly and I understand the clear boundaries set out in this document.
Signature*

Clear
Date Signed*

DayMonthYear
Date
Thank you for taking the time to fill out this document. We look forward to having you joining our programme.
© The Positive Movement Project CIC

The Positive Movement Project is a Community Interest Company, Registered in England, limited by guarantee. Company Number: 12795875
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Access Support - The Wellness Workouts

Emergency Contact

Physical Activity Readiness Questionnaire

Health Care Questionnaires

Acknowledgment