Meditation Information and Consent Form

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* 1. Full Name

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* 2. Date of Birth

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* 3. Phone Number

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* 4. Email Address

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* 5. Emergency Contact

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* 6. Emergency Contact Phone and Email

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* 7. Please describe your experience (if any) of Mindfulness and/or Meditation...

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* 8. What are you hoping to get out of these sessions?

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* 9. Please identify any current mental health concerns (including anxiety, depression, trauma, self harm) Please specify and detail any professional supports you are currently receiving.

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* 10. I consent to attend and participate in a Mindfulness Meditation class with Anna Davies

I agree that I have informed Anna Davies of any physical, psychological or emotional issues which may be triggered by meditation

I agree to participate in activities at my own risk

Agree

Disagree