Mindfulness and Emotional Resilience Course Participant Registration
All information will  be kept confidentially.
Sign in to Google to save your progress. Learn more
Email *
Full Name *
What will you be paying for the course, to book? (Please see website for costs and guide) https://www.positively-mindful.com/groups.html *
What are the main topics you'd like to focus on? *
Required
Could you summarise your main goal in one sentence? (Eg. I'd like to become more calm and learn how to deal with my anxiety in a useful way.) *
QUICK HEALTH CHECK.
Roughly, in the last two weeks, how are you?
Stress levels
I roll with things calmly
I'm SO stressed!
Clear selection
Anxiety levels *
Confident in my ability to manage
Very anxious most of the time
Anger levels *
I deal with things calmly and assertively
Aggressive or holding bitter resentment regularly
Sadness levels *
Mostly happy. Sadness passes easily
I'm stuck in feeling sad, depressed or hopeless
Overwhelm and Burnout levels *
Coping well with the problems of life
Coping poorly, feeling very overwhelmed!
Confusion / Stuckness Levels *
I have a clear mind and can plan ahead well
My mind is confused and I feel stuck
Procrastination levels *
Achieving what I want
Constant procrastination and avoidance
Physical pain/ sickness levels *
Healthy body, relatively pain free
Severe daily aches, pains and physical problems
Do you feel you have any conditions, (phobias, emotional-traumas, triggers etc) or concerns that may be helpful to tell us about?
If not, leave blank
Emergency Contact (Just in Case - Name, number, relationship) Eg. Sally Morbey, 0745885588, Mum. *
SIGN UP: MAKE A COMMITMENT
The satisfaction in my work comes from helping people to achieve their main goal. This only works if you do - If you are willing to practice, which is why I ask people to, literally , sign up to the following:

Check all of these if you agree to: *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy