Mindfulness Based Stress Reduction Retreat Day Your Name* Occupation* Date of Birth* Current Location* Contact Number* Email GP Name* GP Contact Number* 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. Have you experienced any ill-health within the last few years, such as anxiety or depression, and if so, were any medication taken? *YesNo 3. Have you had any life event in the last year that might make the work on the course difficult for you? (I.e. bereavement, divorce, job loss or any major change)? *YesNo 4. Is there anything else that you would like us to be aware of? *YesNo 5. The course involves a commitment to undertake about 40 minutes of daily home practice (as best as you can). Do you foresee any difficulties in setting aside some time for your home practice each day? (Once the course is over, you will leave with an individually tailored daily practice to suit your own lifestyle and needs)? *YesNo 6. Have you had any previous experience of mindfulness, meditation and mindful movement or yoga? If so please specify. *YesNo 7. Where did you hear about this course?* 8. Do you have a professional interest in registering for this mindfulness course? If so, please specify; Mindfulness Pre-Course Reflections Before starting the course it is interesting and useful to reflect and write down your responses to the following questions. There will be an opportunity to review your responses on the first day of the course and to reflect back on your original reasons for undertaking the course when you have completed it. 9. What has drawn me to undertake this mindfulness course? 10. What do I want to get out of doing the course? Mindfulness training is a wonderful tool for life but is not always recommended to undertake depending on your present circumstances; for instance while going through difficult life events such as bereavement, divorce, moving home. If you have any questions regarding your eligibility to undertake the course, please do contact me. I am very happy to hear your personal situation and discuss your eligibility. Once your application is received and assessed, I will contact you to confirm your place on the course or to arrange a telephone conversation to make sure this is the right course at the right time for you. Once your place is agreed please send a non-refundable deposit of £50 to secure your place. The course fee is £250 including the 9 week course, the full day retreat, a workbook and three recordings of the practices. The remaining balance of £200 should be paid by bank transfer or cheque, at least a week before the course starts. I will email you the bank details when your place is confirmed. Fees are non-refundable once the course has started, unless the cancelation is made by the organiser. Please don’t hesitate to contact me by email or telephone should you need any further information.