NEW YEAR online Retreat Registration Form
Confidential retreat registration form for the NY 2020 online retreat
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Name *
Gender and Age *
Email *
Phone *
Occupation and / or Life Situation *
Current meditation practice if any *
Previous retreats attended if any *
Care and Support - please answer the following questions so that we can care for you appropriately. Do you have any current or previous diagnosis or treatment of a psychological or psychiatric illness?   e.g. mood disorders, panic attacks, schizophrenia, clinical depression, generalised anxiety disorder. *
Do you have a vulnerability or history of self-harming? *
Do you have a medical conditions that could require attention or would affect your participation in meditation sessions? e.g. epilepsy, chronic back pain, chronic fatigue *
Do you have a drug and/or alcohol addiction issues (e.g. marijuana, amphetamine, heroin, ecstasy, alcohol etc…) *
Do you have any additional information or comments you would like to convey to the teachers?
By checking the box below, I confirm that all of the above information is correct to the best of my knowledge. I will inform the teachers/managers of any change in my circumstances. *
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