Individual Session Form

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Lottelife individual session Form

Please complete all required fields!

Any personally identifiable information received is kept confidential. All personal information shared will only be shared as necessary for the welfare of the participants. Personal information collected is stored in a secure location and safely destroyed after it is no longer legally required.

Personal Details

your full name(*)

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phone(*)

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email address(*)

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Please indicate your date of birth: (*)

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Emergency Contact

Name(*)

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Phone(*)

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where did you hear about Lottelife?

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Do you have a history of, or have you recently experienced any of the following?

Cardiovascular disease, including angina or heart attack(*)

YESNO

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High blood pressure(*)

YESNO

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Mental illness or psychiatric hospitalization(*)

YESNO

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Surgery, inpatient or outpatient(*)

YESNO

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Past or recent significant physical injuries

YESNO Invalid Input

Recent or current infectious or communicable diseases(*)

YESNO

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Seizure disorder (epilepsy)(*)

YESNO

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Osteoporosis(*)

YESNO

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Diabetes(*)

YESNO

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Back problems(*)

YESNO

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Do you have asthma? (If yes, please bring your inhaler & alert us at the beginning of the workshop/session.)

YESNO Invalid Input

Are you currently pregnant?(*)

YESNO

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Are you currently in therapy or in a support group?(*)

YESNO

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Have you ever, or are you currently experiencing spiritual emergency?(*)

YESNO

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Are you currently taking any medication?(*)

YESNO

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Have you had a Covid vaccine or booster in the last 4 weeks?(*)

YESNO

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Is your general health good?(*)

YESNO

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If you answered “yes” to any of these questions, please explain or elaborate below or alternatively explain in an email.

Medical details

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Do you agree not to consume any alcohol or drugs prior to or during your session/workshop?(*)

YES I agree not to consume any alcohol or drugs prior to or during your session/workshop

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Is there anything else about your physical or emotional situation that we should be aware of?

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Please provide details about any potential concerns here, or anything you feel we should know

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PLEASE READ AND SIGN THE FOLLOWING STATEMENT

I hereby confirm that I have read and understood the above information, and have answered all questions completely and honestly, and have not withheld any information. If I am submitting this form electronically, I agree that my typed name and the digital signature below shall be the binding, legal equivalent of my actual signature.

I have read, understood, and have truthfully answered the above questions.

If I have indicated a potential concern, I have provided details.

Name (CAPITALS) (*)

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Signature(*)

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Date(*)

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If you would like to join Lottelife Newsletter for the latest news, upcoming workshops & links, please sign up here:

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Contact Lotte

Email: [email protected]

Mobile: +61 422 989 551

Skype: lotte.schultz

WhatsApp: +61 422989551

Facebook: lottelife page

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