Mindfulness Course Application Form

Name:Occupation:

Date of birth:

Address:

Your phone numbers:Your email:

Your GP: name and phone no;

Name and phone no of someone to contact in case of emergency:

Please specify which 8 week course you wish to bookdate/location:

How did you hear about Go Mindfully?

To help the instructor, please answer the following questions as fully as possible. The information you give is strictly confidential and will be seen only by the instructor or her supervisor. She will not keep the information after the course is completed.

  1. If you have any physical illness or other limitation that may make sitting, standing, walking, or doing simple exercises difficult for you, please tell us about it here:
  1. If you have had any other ill-health within the last few years, such as anxiety or depression, please tell me about it here including main symptoms:
  1. If you are taking any medication at present, please say what it is/what it is for/any side effects:
  1. Have you had any life event in the last year that might make the work on the course difficult for you (e.g. moving house, separation or loss, work changes)?
  1. Is there anything else going on in your life right now that you would like us to be aware of?
  1. The course involves a commitment to daily home practice of meditations learnt during the sessions, as well as keeping a record of your experiences throughout the course. Do you foresee any difficulties in setting aside up to 45 minutes for your mindfulness practice each day?Please consider and specify when you might do this.
  1. Have you had any previous experience of mindfulness or any other form of meditation practice? If so please specify.

9. If you have a professional interest in mindfulness please tell us a bit about this.

(Please continue by responding to pre-course reflection questions below on p3)

Mindfulness Pre-Course Reflections

Before starting the course please consider as fully as possible the following questions which are a useful preparation for the course. You might also find it interesting to have these responses so you can reflect back on your original reasons for undertaking the course when you have completed it.

Please return a copy to us with your application form.

What has drawn me to mindfulness?

What are my expectations of the course?

What do I want to get out of doing the course?

PLEASE COMPLETE FULLY AND RETURN ALL 3 PAGES, THANK YOU

The course instructor will be contacting you once you’ve returned this form to talk through with you what’s involved on the course, answer any questions you may have and to check with you whether it’s the right course at the right time for you.

If you have any difficulties during the mindfulness course, it is important that you tell the instructor so she can guide you more effectively. Please also realise that you need to take responsibility for yourself, and seek your own appropriate support if necessary.

Please return completed booking form by email to or by post to Go Mindfully, c/o 43 Peldon Court, Sheen Road, Richmond TW9 1YT

Many thanks,

Go Mindfully 2014