Yoga & Voicework with Kim Sheehan Intake FormAs I work with a number of modalities, please fill out the relevant boxes provided Name * First Name Last Name Name of emergency contact * First Name Last Name Email * Address * Would you like to be added to my mailing list? I send out details about upcoming classes, workshops, retreats online and in London and Cork. * Yes No How did you first find out about the sessions I offer? * Word-of-mouth Kim Sheehan mailing list Internet search Instagram Twitter Facebook LinkedIn Other If you chose 'other', let me know how you heard about these sessions below. What is your main aim in working with me? * Which modality would you most like to work in and why? Yoga, Voicework, EFT and/ or Yoga for Cancer? * Have you attended a yoga class before? * Yes No If yes, how long have you practised yoga and what style of yoga have you practised? * Whilst yoga may be practised safely by most people, there are certain conditions that require special attention. If you are unsure, please consult your GP before commencing class. Abdominal disorder or recent surgery Unspecified back pain Joint replacement Hip problems Heart disorders Low blood pressure Arthritis (osteo or rheumatoid) Spinal Injury Shoulder or neck pain High blood pressure Joint pain Other Feel free to use this box if you need to give further information on a condition. These conditions may affect your practice and so it will be useful for your tutor to be aware of them. Asthma Anxiety/depression Epilepsy Respiratory issues Sensory disorder affecting eyes or ears Diabetes Auto-immune disorder (e.g. M.E., M.S., Lupus etc.) Balance affecting disorder Migraine Other (do feel free to discuss with me) Cancer - Please fill out questions below; Please indicate below if you do not wish to declare medical information. Do be aware that as your yoga teacher I cannot give any modifications or alternatives that may be appropriate, for conditions that have not been declared. What type of Cancer were you Diagnosed with? What treatment are you currently receiving, if any? Please state any other prescribed medicines you are taking? Please describe in detail how you would like to feel after a session with me. Do you have a disability or special requirements? Declaration * I declare that the information in this form is true and complete. I accept that it is my responsibility to keep the yoga teacher updated of any changes in my health or medication. I consent to participating in yoga classes whether online or in person, and where necessary I have received prior permission from my medical professional(s). Signed and Date (###) ### #### Data Protection & Privacy Notice * In line with the new GDPR legislation, this notice tells you what personal information I hold and why, and what your rights are. Once you have read it please complete and sign the declaration/statement of consent at the bottom. Ways I collect your data: If you have a one to one appointment for reflexology or yoga I collect information via client health/registration questionnaires. This may be completed online, by emailed document or in person on paper. You may have signed up to my newsletter either online or via a paper form. You may have attended a workshop or retreat or other event run by me. You may have emailed me directly. Processing your Data Your data may be used in the following ways: To enable me to provide you with a professional service (for example: making appointments, keeping treatment notes and follow-up information and support etc.). To contact you about services I offer. With your consent/request, information may be shared with other health professionals. I will never share your personal information to third parties without your express written permission or request. Retaining your data: I have a legal obligation to retain your client records as a health care practitioner for the following reasons: Insurance and accounts records for 7 years children’s records until they are 25 (26 if treated at age 17) CNHC requirements to retain information for 8 years In addition, information collected about your current health and medical history is for me to fulfil my role as a health care practitioner bound under the Confidentiality clauses of the Code of Practice and Ethics of both the BWY and the AoR. Data Security: My database is registered with the ICO under the Data Protection Act and is stored on a passcode protected laptop. It is also backed up on a Microsoft cloud server which is GDPR compliant. Emails are stored by a passcode protected account and are deleted on a regular basis unless required for legal purposes. Any data accessible via my smartphone is also protected by a passcode and is GDPR complaint via Apple software. My mailing list is held via Mailchimp in a passcode protected account and is GDPR compliant via Mailchimp procedures. Paper client notes are filed securely in my home or carried by me personally. Your Rights: You are entitled to request access to the data I hold about you, to verify it is lawfully processed. I will respond to any request within 30 days. You also have the right to request correction of any data that you feel is inaccurate or incomplete. At any time you may unsubscribe/be removed from my newsletter and other marketing. You may ask to be deleted from my database and have your notes destroyed once the legal timeframe outlined above has lapsed. I have seen this document and understand that you will hold and use my personal information, using it in order to provide me with the best possible treatment options and advice in line with the statements above. Signed name and date (###) ### #### Client’s phone number (###) ### #### Emergency contact phone number (###) ### #### Thank you! Thank you so much! See you next time.
