Distance Learning Mindfulness Course – Application Form

Name

Your Email

For the one-to-one sessions, I prefer using
SkypeGoogle HangoutsTelephone

Skype Name

Phone Number (including country code)

How did you hear about this course?

What is your main reason for participating in
the mindfulness course?

Any previous experience with mindfulness
meditation or any other type of meditation?

Do you have any physical, medical or mental
health condition that we should be aware of?
(Answering yes does not necessarily exclude
you from attending the course.)

Are there any particular stressful elements
in your life at present? (Significant changes in
your circumstances, e.g. relationships, work,
where you live, health).

Are you aware that participation on the course
requires approximately 45 minutes of practice
a day, for the duration of the eight weeks?

2. PLEASE NOTE:

Mindfulness-based Stress Reduction (MBSR) has been found to be effective in promoting health and wellbeing for individuals facing a wide variety of challenges. However, MBSR may not be an appropriate choice for you at this time.
This may be the case if you are dealing with:

• An acute medical condition requiring frequent intervention or treatment.
• Substance abuse or dependence (currently or within the past year).
• Psychological issues including: suicidality, psychosis, trauma, severe depression or other major psychiatric diagnosis.

MBSR is not psychotherapy, and is not a substitute for mental health counselling, medical care or substance abuse treatment. You will have an opportunity to talk, one on one, with a course instructor prior to signing up for the course and it is important that you discuss any questions or concerns you have regarding your specific situation. We realise the personal nature of this information and we hold your responses in confidence. Please note that final decisions about participation in the course will be made by the course teachers.