Retreat into Simplicity

Name

First NameLast Name

Please state which retreat date/dates you are interested in.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

example@example.com

Please state any areas of physical discomfort or pain.

Describe onset of discomfort or pain

Frequency - please select the most accurate

At what time of day is the pain at its worse?

Have you ever received therapeutic massage for a specific problem or injury?

Was the treatment used effective?

Please list any other health concerns including allergies.

Are you currently seeing any healthcare professional for any health concerns, and what treatments are you undergoing.

Care of clients undergoing or having undergone oncology. Please describe type of cancer (location, hormonal or not, whether you are undergoing treatment or how long since treatment). Some retreats may include the use of essential oils. It is imperative I am aware of any contraindications to keep you safe.

If not already listed, please list any current medications.

Please state any other information you feel Katie should know.

Retreat Policy:

Client services and chart information are confidential. Written authorization is required from you to release any information.

• Please turn off your mobile phone for optimal relaxation

• Please arrive on time for each session

• Please arrange suitable insurance cover in case of cancellation. This event is non-refundable.

Client Agreement:

I understand that the retreat will include elements of physical exercise (yoga asana).

I undersand that at any time I feel pain or discomfort during the session, I will immediately inform Katie so she can suggest alternatives. I will discontinue with any movements that do not feel beneficial.

I acknowledge that the retreat is not therapy, although it may be therapeutic.

I have stated my medical conditions, and will update Katie of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I will not hold Katie liable whatsoever arising from failure on my part.

The retreat constitutes a brave space where people may share private information. I agree to keep any information disclosed confidential. I will not directly refer to anyone else's experiences, or give advice on same, whether that person is known to me or not. What goes on in retreat, stays in retreat.

By my electronic signature below, I agree to the policy and retreat agreement above.

Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Date

Mini Retreat with Petalouda Yoga & Wellbeing

Health Questionnaire