Workplace Reset — Pre-Session Screening Questionnaire

Workplace Reset - The Practice of Deep Rest and Restore Pre-Session Screening Questionnaire

Please complete this short questionnaire before your first session. Your responses help the facilitator run a safe, well-adapted practice for you. All answers are confidential and used only for this wellness programme purpose.

Name

Date

dd-mm-yyyy

Company

01. Do you have any diagnosed neurological condition, including epilepsy or seizure disorders?

Yes

If yes, Describe

02. Do you have a diagnosed psychiatric condition (e.g., schizophrenia, bipolar disorder, active PTSD, psychosis) or a neurodivergent diagnosis?

Yes

If yes, Describe

03. Have you experienced any severe depression, suicidal ideation, or acute emotional crisis in the past 6 months?

Yes

04. Are you currently pregnant, or is there a chance you may be?

Yes

05. Do you have any diagnosed heart condition (e.g., arrhythmia, decompensated heart failure)?

Yes

If yes, Describe

06. Are you currently taking any medication?

Yes

If yes , List

07. Have you practiced meditation, yoga, or relaxation techniques before?

Yes

If yes, Briefly Describe

08. Do you have any physical limitations that make lying down for 20-45 minutes uncomfortable?

Yes

If yes, Describe

09. Is there anything about your work, stress, sleep, wellbeing or anything you would like the facilitator to be aware of?

10. Do you consent to participate in this guided relaxation session, understanding you may stop at any time?

Yes

Consent & Acknowledgment

Workplace Reset -The Practice of Deep Sleep and Restore is a guided relaxation practice and is not a substitute for medical or psychiatric care. It is not recommended as a stand-alone treatment for epilepsy, active psychosis or acute mental health crises and individuals with these or other significant medical conditions should consult a qualified healthcare professional before participating. Please disclose any relevant health information above so the facilitator can adapt the session appropriately.

By signing below, I confirm that the information provided above is accurate to the best of my knowledge, and I voluntarily consent to participate in this session. I understand I may stop, rest, or leave at any time without explanation.