GROUP RETREAT Health & Lifestyle FORM

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.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Gender

Occupation

Date of birth

Place and country of birth

Time of birth (if known)

Relationship status

If other please specify

Do you have children? If yes, how many, what gender and age

Do you have siblings? If yes, how many, what gender and age

General Practitioner

General Practitioner Name

General Practitioner Address

Emergency Contact

Please make sure your emergency contact knows you are on an Arrigo Programme retreat.

Emergency Contact Name and Relationship to you

emergency contact phone

Country

(###)

###

####

Emergency contact Email

Do you have insurance? Please give details

How did you hear about us?

If other, please give details

Your Health

Do you have any allergies?

How would you describe your general health?

How would you describe your general energy levels?

How many hours do you sleep a night on average?

Do you have any health issues?

Please give details

Do you follow a special diet for health reasons? E.g. wheat-free, vegan etc. Please describe below.

Please list any currently prescribed medications, reason for use, amount and frequency. E.g. Insomnia – Diazepam 5mg at night.

Please list any alternative/homeopathic medicines including reason for use, amount and frequency.

Please give details of any serious health conditions in your family medical history.

Please give dates and details of any major surgeries/accidents/trauma.

Your Lifestyle

Please indicate your general daily habits

Smoking

Alcohol

Caffeine

Water

Your general eating habits

Do you currently or have ever used any recreational drugs?

If yes, please list which drugs, when and how often?

Have you ever suffered from epilepsy or fits

Please indicate the level of exercise you usually take on a daily basis?

Please indicate how much time you take to relax on a daily basis?

What are your self-care practices?

YOUR EMOTIONAL WELL-BEING

How stressful do you generally find your life on a daily basis?

Do you worry about things on a daily basis?

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.

If yes, please describe any treatment and medication you received for this and the relevant dates.

Is there anything else you would like us to know about your mental health?

Is there anything you would like us to know about your personal relationships?

Do you have any concerns about working in a group setting?

Please use this space to tell us anything else about you and your life that you think we should be aware of.

Please tell us your purpose for joining this retreat.

The Future

This is an opportunity to write about your aims, your hopes and desires. Please continue on a blank sheet should you wish to write more.

What does your ideal lifestyle look like?

What is your ideal version of your health?

What changes would you like to see come to fruition in your life?

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.

Name

First Name

Last Name