Medical Questionnaire | Mindful Mind Clinic

Strictly Confidential

Catriona Curtis, UKCMM Accredited Practitioner/ Mindfulness Teacher

Professional and Ethical Practice

I, Catriona Curtis, am committed to upholding the highest possible standards of professional ethics and codes of practice in the interests of client care and confidentiality.

Mindful Mind Clinic – Workshop

The following sets out some basic information about the session/retreat that you are attending with the Mindful Mind Clinic, as well as briefly asking you a few questions. We kindly ask you to read it carefully and as a required formality, return it to us signed by you at the time of booking or within 7 days of receiving this form. Your place will only be secured officially on receipt of this form.

Looking After Yourself:

The practices in each session involve sitting, standing and mindful movement, cold water therapy baths, grounding in bare feet on grass, breath work, sound baths, reiki and meditation.

Please only do what is safe and suitable for you, based upon your state of health. If in any doubt please let us know straight away. You may need to consult your doctor for advice as we are not medically trained to give advice on medical issues.

This workshop is designed to educate and nourish your mind and body, you can choose to partake in all practices or just some. That choice is always yours.

Medical Questionnaire & Personal Information:

Please ackowledge that you have read this. This section is extremely important as we need to ensure your health is suitable to be able to take part in cold water therapy baths and breath techniques.

Please declare any medical conditions that we should be aware of below: Type none if there aren't any

By ticking this box you acknowledge the following. Disclaimer - Cold Water Therapy: is not advisable for anyone who is pregnant, has had a heart attack in the past 2 years, anyone with a pacemaker or anyone suffering from nerve related illnesses.

By ticking this box you acknowledge the following. Disclaimer - Sound Therapy: Sound therapy is not advisable for anyone who is currently pregnant, has a pacemaker or has had surgery of any type in the last 12 weeks.

By ticking this box you consent to the following. I am agreeing that the information given by me above is correct. I agree to perform breathing techniques and consent to entering cold water at 15 degrees celsius and below at my own risk and understand the dangers and the effects of cold water immersion during and after exposure to it. I consent to attending a sound bath and reiki healing. I consent to holding all responsibility for any injuries, ailments or after effects that may occur during or after breath techniques, cold water immersion, sound bath, reiki with Catriona Curtis at the Mindful Mind Clinic Ltd. and any 3rd party facilitator. Therefore I agree to waiver all responsibility and to not make a claim based on the above.

Please note any dietary requirements or food allergies?

Are you pregnant? (cold water immersion and soundbaths is not recommended for pregnant women)

Please tick to acknowledge that you have read this. Privacy Notice. We are required by law to inform you that we intend to hold, in secure paper and electronic format, only basic information, as contained in this form.

First Name

Last Name

Phone

Address

Date of Birth

Next of Kin Name

Next of Kin Phone Number

Consent to join mailing list Tick box if you DO NOT want to be signed up to the mailing list.

I acknowledge that I have read all pages of this form and understand all practices within the Mindful Mind Clinic workshops as dated below, and confirm that such sessions have been explained and outlined to my satisfaction. I have read and understood the disclaimer section. All information provided by me to the practitioner is accurate, to the best of my knowledge. If I have been requested by Catriona Curtis to seek consent from my medical doctor/ consultant then I have done so or will do so prior to partaking in cold water therapy.

If I have been requested by Catriona Curtis to seek consent from my medical doctor/ consultant then I have done so or will do so prior to partaking in cold water therapy.

Signed by client at time of booking

Select a date

To be ticked on the day of workshop. I agree that all of the above information, as previously filled out by me at the original time of booking, remains accurate and correct.

Below is only to be signed on the day of the workshop by the client:

Below is only to be signed on the day by the programme facilitator:

Date

I accept terms & conditions. Booking Terms and Conditions Cancellation policy: Any event booked with The Mindful Mind Clinic directly or through a third party booking platform will be subject to the following terms and conditions. Workshops Amount to be forfeited of the total ticket price More than 31 days prior to event – 50% of ticket price Less than 31 days prior to event – 100% of ticket price Cancellations are to be requested in writing to info@mindfulmindclinic.ie from the email address originally used by the customer who purchased the ticket. Once your booking has been made we will make every effort to provide you with the booking arrangements but reserve the right to alter or cancel the whole or part of the events in the event of happenings outside of the control of Mindful Mind Clinic. Reasons for doing so may include but shall not be limited to such as matters of civil strikes or conflict, extreme adverse local weather conditions or weather warnings, natural disasters, embargoes, terrorist activity, fire, flood conditions, strikes or labour disputes, pandemic’s, government orders or any other force majeure event. No compensation will be paid for these cancellations out of our control, however you will receive a similar workshop package at a later date to the value of what you have paid. Liability Mindful Mind Clinic Ltd. takes great care in organising our events however we will not be held responsible for the day to day running of the hotels, restaurants, private hire venues or any other suppliers not owned by Mindful Mind Clinic nor are we responsible for any additional expense, disappointment, delay or inconvenience resulting from any other supplier. Mindful Mind Clinic are not liable for the acts, errors, omissions, representations, warranties, breaches or negligence of any such supplier or for any personal injuries, death, property damage, lost property or other damages or expenses resulting there from. We are an insured operator. Special Requirements Mindful Mind Clinic will endeavour to accommodate the special requests of clients, including (without limitation) dietary, allergies and mobility requests. It is essential that all special requirements are brought to the attention of Mindful Mind Clinic at the time of booking and are included in the booking form. When you book a workshop with Mindful Mind Clinic you are deemed to accept in full our terms and conditions.

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Strictly Confidential

Professional and Ethical Practice

Medical Questionnaire & Personal Information:

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Look after your mind and it will take care of your body.