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* 1. What is your Full Name?

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* 2. Please enter the best telephone number should we need to contact you:

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* 3. Please enter your date of birth:

Date

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* 4. Do you access Group Exercise Classes for support with a diagnosed condition? If yes, please state what it is: *

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* 5. Have you discussed and/or sought verbal permission from your GP/ Specialist or mental health professional? If yes, please state who? *

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* 6. If not, please state your reasons for seeking support through 3-1-5 Group Exercise Classes? *

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* 7. Are you currently in Mental or Physical distress *

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* 8. Does your condition affect your ability to work?

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* 9. Does your condition affect your daily activities?

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* 10. Do you feel that your mental health would severely deteriorate without access to Group Exercise Classes over the next few weeks?

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* 11. Do you feel that your physical health would severely deteriorate without access to Group Exercise Classes over the next few weeks?

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* 12. I confirm my above answers are honest and true to the best of my knowledge, and I am responsible for advising 3-1-5 if any of the above circumstances change.

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