8 Week Course - Registration Form

8 week Course - Registration Form

Please return this form via email to:

All information on this form is strictly confidential. If there are any questions you are uncomfortable answering, we can discuss them over the phone.

First Name: ______

Surname: ______

Email: ______Phone No’: ______

Address: ______

Please provide the following contact details. I will only contact in the case of emergency:

GP Name/Surgery:______

GP Phone No’:______

Emergency Contact:______

Phone No’: ______

Relationship to Emergency Contact: ______

How did you hear about the course?

What would you like to get out of the course?

Have you ever practiced mindfulness? If so, for how long?

Do you have any special requirements, learning needs or any health or medical condition you think I should know about?

Have you ever experienced any mental health difficulties such as depression or anxiety? If so, please can you say a little about this below.

Do you have any current difficulties with stress, depression or anxiety?

Are you currently on medication? If so please list.

Confidentiality

All information is confidential and all discussions between you and myself are also strictly confidential. However, there are some limitations to confidentiality that you need to be aware of: I reserve the right to break confidentiality and contact the appropriate services should you be considered to be a risk of harm to yourself or others. I will make every effort to inform you prior to taking this action.

Disclaimer

The eight-week course is aimed towards those who wish to improve wellbeing, and suffer from stress, mild depression, and anxiety. This course is not appropriate for those with post-traumatic stress disorder (PTSD), those suffering from severe depression, or those who are at risk for suicide, or other serious mental health condition such as psychosis or dissociative disorders. It is also not recommended for those that have had a recent bereavement, or other significant life crisis, or those with current substance misuse. With permission from, and under the guidance of your GP and/or mental health professional, private sessions may be of benefit. Please consult me directly to discuss your options or to determine if this course is right for you.

To the best of my knowledge and belief all information on this form is accurate. I understand the terms and conditions of participation. I have had the opportunity to personally discuss with the instructor any concerns that I might have.

______

Signature(electronic will suffice) Printed Name Date

Please return form via email to