Yoga for Autism FORM under 18

Parent's Name *

First

Last

Child's name and age *

Address *

Parent's phone number *

Parent's email *

1. Has your child attend yoga therapy classes or yoga classes before?

2. Main areas of concern: *

3. Communication *

4. Which of the below describes your child the best, doesn’t have to fit into all of the description – choose one if possible *

Busy, fun loving, energetic, enjoy being around other people, love to laugh, talker more than listener, great motivator, forgetful, short attention span, low patience, messy.
Easy to please, easy going, well behaved, empathetic, trustworthy, and loyal, great listener, peacemaker, struggling to make decisions, not sharing own opinion, low self-esteem.
Perfectionist, high standards, highly intelligent, deep thinker, creative, planning, tidy, introverted, very emotional, getting distressed, negative thinking, worrying a lot, pessimistic, idealist, possessive, intense.
Leader, forceful, extroverted, pragmatic, great, supportive friends, high self-esteem, independent, argumentative, competitive, stubborn.

5. Does child have any medical conditions? Any medication? Any diagnosis? Any allergies? If parent attends session – please specify above for child and parent. *

6. In the past 6-12 months did the child go through any surgery. If parent attends session - please specify for child and parent *

7. Energy Levels of the child: 0-very low, 10-very high

Selected Value: 0

8.Sleep Pattern: 0-doesn't sleep at all , 10-sleeps all night.

Selected Value: 0

9.Stress management: 0-doesn't cope with stress , 10-copes very well

Selected Value: 0

10. Is there any existing support / any support plan in place? *

11. Any known triggers? *

12. Special Interests, child’s favourite activities / games / likes (for example numbers, colours, Minecraft etc) *

13. Any further information that may be relevant.

14. What would be your desired outcome of those sessions?

15. Consent form - The NSPCC recommend that good practice for hands-on adjustment includes the following: • Stating positive reasons for using manual handling • Providing information to parents about the “hands on adjustment process” • Obtaining written consent from parents and young people That I am in line with the above guidance this section of the questionnaire is to make you aware that there may be circumstances where I need to do this and that by signing this questionnaire at the end you give yours and your child’s(rens) consent for appropriate and safe hands-on adjustments to be undertaken where necessary. To ensure your child(ren) does a posture safely and does not hurt themselves or other children in the class it may be necessary in some circumstances to adjust your child(ren). I would instruct and demonstrate first and then if they cannot get into the pose with ease, I would help them by lightly adjusting their arms or legs (prior to doing this I would ask their permission). Furthermore, if your child(ren) are in distress or have hurt themselves it may be necessary for me to pacify them or apply a bandage or an ice pack to the injury. Once again, I will ask permission from your child(ren) before doing so and then if necessary, I will contact you. I, Anna Smithers, will use hands-on adjustment and/or apply reasonable comfort/first aid if your child(ren) requires it during my yoga lesson, and if the instruction cannot be communicated in any other way, i.e. either verbally or through demonstration. The adjustment/reasonable comfort/first aid will be made by my first verbally obtaining the permission of the child(ren), and subsequently touching the child on the appropriate part of the body to make the appropriate adjustment. Are you happy for me to adjust your child(ren)? *

16. During the session I possibly will be using therapeutic touch, are you happy for me to do so? I will always ask for permission before *

17. From time to time it is possible the photo will be taken for marketing purpose. Do you agree for the photo of you and your child(ren) being taken? *

18. To prove effectiveness of the program I need to present child’s condition and progress during the sessions (if any). No personal information will be disclosed, only male/female and age. Case study will be also available on the OLY website. Do you agree? *

19. Would you like to receive emails with forthcoming Orange Lotus Yoga events and newsletters? *

20. How did you hear about this service? *

21.By submitting this form I agree to the declaration below. *

Yes, I agree

I strongly recommend that you consult with your physician before beginning any program. You/ your child should be in good physical condition and be able to participate in physical movement and make suggested lifestyle changes if you feel you are able. I am not a licensed medical care provider and I am not able to diagnose, examine, or treat medical conditions of any kind, or in determining the effect of any specific exercise on a medical condition. You should understand that when participating in any program, there is the possibility of physical injury or unwanted effects from making lifestyle or dietary changes. If you engage in this program, you agree that you do so at your own risk, are voluntarily participating in these activities, assume all risk of injury to yourself, and agree to release and discharge Anna Smithers from any and all claims or causes of action, known or unknown, arising out of suggestions made. I understand that there is no guarantee on effectiveness of the programmes, and I will not hold Anna Smithers responsible in any way for the outcome, either during or after yoga session. I confirm the above information is correct. I understand that it is my responsibility to :- • Check with my doctor if my child has any difficulties or concerns about my ability to participate in the yoga class. • Advise the yoga tutor of any change in my medical information. • Follow the advice given by my doctor and/or yoga tutor. • I understand that my child(ren) take part in this class at my own risk, and that Anna Smithers accepts no liability for any damages or injuries. • If sessions are provided online, I will take responsibility for child’s safety.

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Yoga for Autism FORM under 18