Registration Form | Peace Of Mind Medita

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CLIENT REGISTRATION FORM

Please complete this form prior to starting sessions.

All information is confidential and helps ensure your experience is supportive, safe, and tailored to your needs.

YOUR DETAILS:

First & Last Name

Email

Home Address

Pronouns (Optional)

Date of Birth

Phone

EMERGENCY CONTACT DETAILS:

Emergancy Contact Name

Telephone no.

ABOUT YOU:

Where did you hear about Peace of Mind Meditation?

What are you hoping to gain from these sessions?

Have you practised meditation before? *

No

Yes

If yes, please give details

HEALTH & WELLBEING:

Do you experience any of the following? *

High blood pressure

Low blood pressure

Fainting/dizzy spells

Asthma

Breathing difficulties

Hearing impairment

Restricted mobility

Partially sighted

Depression

Anxiety

N/A

If you ticked any of the above, please provide details, including how this may affect your meditation practice:

NEURODIVERSITY & ACCESSIBILITY:
Peace of Mind aims to be inclusive and supportive of all needs. If you are neurodivergent and feel comfortable sharing, please let me know how I can adapt sessions to best support you:

Do you have any access needs or mobility considerations you'd like me to be aware of, so I can ensure your experience is comfortable and supported?

Any other health concerns or relevant information you'd like to share?

MENTAL HEALTH CONSIDERATIONS:
Meditation can be a powerful tool for wellbeing. However, if you are currently under the care of a mental health team or healthcare provider, or have been diagnosed with any of the following conditions, we ask that you obtain their consent before attending:

Do you experience any of the following? *

Clinical Depression

Bipolar Disorder

Epilepsy

Schizophrenia

N/A

If you ticked any of the above, please either:

Provide a letter from your mental health team/healthcare provider, OR
Sign the declaration below to confirm you have verbal consent:

DECLARATION:

I confirm that I have informed my mental health team/healthcare provider that I am attending meditation sessions. I agree to notify them if my health or symptoms change during the course.

I confirm the above information is correct.

Full Name

Date

Your Signature

GDPR & DATA PROTECTION:

To comply with GDPR, please tick the boxes below: *

I agree for you to store my data

I agree for you to use my data so that you can provide me with information about any future courses that you may be running.

Thanks for submitting!

Address

Address: Studio 1, 46-47 Fish Quay, North Shields, NE30 1JA

Phone

07766933216

Email

peaceofmindmeditation@yahoo.com

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COPYRIGHT, PEACE OF MIND MEDITATION 2025
BUSINESS BOUNDARIES | REGISTRATION FORM

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