PH MBCT Course - Registration Form
Thank you for your interest in this course. The aim of the course is to promote cultivation of mindfulness. To ensure the course is suitable for you at this time, we need to ask some questions about your health and wellbeing. Please be assured that the information you provide will be treated confidentially.
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Email *
PERSONAL INFORMATION
First Name *
Surname *
Mobile Number *
Date of Birth *
Gender *
Place of Work *
Specialty *
Do you work full-time or part-time? *
Name of emergency contact *
Contact details of emergency contact *
Do you have past meditation experience? *
What is your reason for registering for the course? (e.g. mental health, stress, physical health, personal development etc.) What do you hope to gain? *
Will you be able to attend the course? *
Will you be able to attend all the sessions? *
ABOUT YOUR HEALTH
Do you have any physical conditions or limitations that might make sitting, standing, walking or gentle yoga difficult for you? If yes, please give details *
Do you have any mental health problems such as depression or anxiety? If yes, please give details *
Have you deliberately harmed yourself in the past? If yes please give details
Have you ever attempted to take your own life? If yes please give details
Are you currently taking any medication for any physical or psychological conditions? If yes, please give details
Are there any current circumstances which might be placing you under additional stress e.g. current depression, anxiety, psychotic illness, drug and/or alcohol dependency issues, stressful life changes (e.g. bereavement, relationship breakdown, loss of home, job etc)? If yes please give details *
Do you have social/family support *
Is there anything else that we need to know that has not already been mentioned?If yes please give details *
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