MBSR Booking Form

Your Name*

Contact Number*


Email

Emergency Contact Name*

Emergency Contact Number*

1. Do you have any physical illness, disabilities that may make sitting, standing, walking, difficult for you:

YesNo

2. Are you experiencing any major life event such as bereavement, divorce, job loss or any major change?
YesNo

3. Are you experiencing any ill-health, such as anxiety, depression or others?

4. Is there anything else that you would like us to be aware of?
YesNo

5. Have you completed an MBSR or MBCT course or equivalent mindfulness courses? Please specify:
YesNo

6. Healthy snacks and drinks are provided. Do you have any food allergies?
YesNo

7. Where did you hear about this retreat?