121 RETREAT Health & Lifestyle FORM Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Profession/Occupation * Gender * TELEPHONE NUMBER * DATE OF BIRTH * Emergency contact * Emergency contact number * Country (###) ### #### Emergency contact gender * Emergency contact emergency contact address * Address 1 Address 2 City State/Province Zip/Postal Code Country emergency contact marital status * emergency contact relationship to you * Your GP name and number * Please indicate any special dietary requirements or food allergies (E.g. vegetarian, wheat-free etc) The following questions are to help us ensure that The Arrigo Programme is right for you at this time in your life. Please answer all of the questions and provide as much detail as you can where relevant. This information will be stored confidentially. How would you describe your general health * How would you describe your energy levels * Please list any significant past or present medical conditions that affect your physical, psychological or emotional wellbeing, giving details, dates and any prescribed medication. * Have you ever suffered from epilepsy or fits? YES NO Please list any currently prescribed medications/alternative medicines eg Homeopathic/ Chinese/Ayurvedic. * Please list below the reason and include amounts and frequency. (Eg. Insomnia - Diazepam 20mg once a day). * Please give dates and details of any major surgeries/accidents/trauma. * Please list any personal psychotherapy/counselling or coaching you have had and any group therapy/work you have participated in in the last 10 years including approximate dates and duration for each. (Eg. Counselling once a week 2010-2012). Have you ever experienced any nervous or mental health issues? This includes clinical depression, anxiety, panic attacks, bipolar, schizophrenia, nervous breakdown, burn out and obsessive-compulsive disorders. * YES NO If yes, please describe any professional treatment and medication you received for this and the relevant dates. * Is there anything else you would lie us to know about your mental health? * Please let us know about your alcohol use. * If yes, please list which drugs, when and how often. Do you currently or have ever used any recreational drugs? * YES NO If yes, please list which drugs, when and how often. * Are you currently aware of having any substance or behavioural addictions? This includes any food disorders such as anorexia and bulimia. * yes no If yes, please provide details. * Do you suffer from any non-food allergies? * YES NO If yes, please give details. * How many hours do you sleep on average per night? * Have you experienced any significant life events which you would describe as traumatic? (E.g.Sexual assault, sudden death of a loved one, physical trauma). * yes no If yes, please provide details including dates. If yes, please provide details including dates. * is there anything you would like us to know about your personal relationships? * What are your spiritual / energetic practices? * What is your level of self-care? * How much time do you give yourself? * Is there any reason why you might find it challenging to participate in a group retreat? * What are your needs within a group dynamic? * Please use this space to tell us anything else about you and your life that you think we should be aware of. * Terms and Conditions * I confirm that all my given information is up to date and fully accurate. I understand that if there is any change to my personal or therapeutic situation, I’ll inform The Arrigo Programme facilitators immediately. Failure to do this could result in being asked to leave the retreat. I understand that The Arrigo Programme is based on psychological, anthropological, holistic and spiritual principles that may or may not benefit my personal growth. I agree to take responsibility for my full participation in the retreat. I accept that The Arrigo Programme Facilitators are not all licensed psychotherapists or psychologists. I agree to respect total confidentiality of each participant on The Arrigo Programme including their comments, shares and experiences, and I agree to keep all such information to myself. I will not disclose other participants by name, description or other information that would breach their anonymity. I also accept that photography, video and sound recordings are not permitted of the retreat. I acknowledge that my participation in the retreat is at my own risk. While I am on the retreat, I take full responsibility for any injury, illness, property damage or loss. The Arrigo Programme disclaims all liability for any illness, injury, death, property loss or damage, caused by negligence of breach of contract, breach of duty, by any members of staff, which occurs while you are on the retreat. I agree that this release will also bind any family members and/or per- sonal representatives. The Arrigo Programme reserves the right to ask any participant to leave the retreat without financial reimbursement. I agree to indemnify The Arrigo Programme Founders and their staff for any liability and cost which may occur as a result of any breach of contract on my behalf. Furthermore, The Arrigo Programme will not be liable for any other direct and indirect loss, cost or expense of any nature, however caused. I have read and understood the retreat Ground Rules and I agree to abide by them. I have read and I agree to these Terms and Conditions. YES NO Name First Name Last Name Thank you!
