MINDFUL SELF-COMPASSION COURSE
Booking form
Thank you for filling out this form. Irealise the personal nature of these questions. Please be assured that the completed forms will be kept confidential and shredded at the end of the course.Please return by email or if you prefer post to Go Mindfully c/o 43 Peldon Court, Sheen Road, Richmond TW9 1YT
Extra Information: The course is a really rich experience, with new meditations, guided exercises and self-reflection alongside group discussion. The course is better described as resource building rather than a meditation course. There's quite a lot of material to get through, and we shall be presenting new themes to you each week. There is less emphasis on formal meditation practice than on standard mindfulness courses, which means that the regularmeditationat the start ofeachsession is usually only about 20 minutes, with subsequent in session practice similarly relatively short. Youareencouraged to be more self-directed in your home practice. There are plenty of meditations for you to try out, and you are invited to set your own pace - the potential of this is developing a practice that is really attuned to your own needs and is truly an act of self care.Developing more self-compassion involves necessarily recognising the areas of tenderness and difficulty that you may have experienced/are experiencing. For this reason we ask you to consider in this form your wellbeing and willingness to engage with the programme at this time. Please do give me a call if you have any questions or concerns at all, and if we haven’t met before I will in any case be arranging a brief telephone chat with you to meet you and introduce myself and the program to you.
Thank you for completing this form as fully as possible, best wishes Zoe
Dates
Please check the following dates of the course you are applying for.You must attend the first session. If you have to miss a session it’s OK but missing more than one will considerably affect your engagement so we encourage you to make sure you can attend as fully as possible.
Friday mornings 10-1pm 12th May to July 14th 2017 at Vestry Hall, Paradise Road, Richmond TW9 1SA
Retreat afternoon 2-6 25th June at same venue
(no class at half-term 2nd June)
Cost
The cost of the course is £280 – a non refundable£50 deposit is required to book your place now and the remaining payment is due 1 week before the start of the course, i.e. by 5th May. Once you have started the course the fee is non-refundable. To apply for a place please return this form completed, along with a non-refundable deposit of £50 via BACS to
Go Mindfully, Ref: MSCRich17Account 81891820, Sort code 40 38 18. Thank you.
Please state you have checked dates : Yes / No (delete as appropriate)
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living with partner divorced widowedChildren: (please circle) Yes No Number, ages Children living with you? Yes No
Do you take prescription medication? Name and purpose:
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When and with whom did you complete 8 week Mindfulness course or equivalent?
Are there any events or health issues that are relevant to the way you feel these days that we should know about?
Please take a moment to share why you want to attend this course:
What do you care most about?
What gives you pleasure?
What are your greatest concerns?
Informed Consent – please sign to agree
I understand that my participation in this program is voluntary and I am free to withdraw at any time. The course fee is however non-refundable once the course has started. At the present time, I am planning to participate in the entire 8- week course, including the retreat afternoon. I understand there may be times during the class that I will feel emotionally uncomfortable. If I am having difficulty in the class, I agree to contact the instructor and let them know. During the 8 weeks of the class, I can be contacted by email by my instructors.
I understand that practicing every day will create the most benefit from the programme. The suggested homework is to practice mindful self-compassion 30 minutes/day (formally or informally).
Name:date:
Many thanks, Zoe
Feb 2017