REGISTRATION FORM

PRE-COURSE QUESTIONNAIRE

THANK YOU

Thank you for registering your interest in a mindfulness course with The BeingWell.

Please could you fill in the registration form below. The course teacher will then be in touch with you to have a 10 to 20 minute chat with you based on your answers. You also have the opportunity then to ask any questions if you would like to.

All information is strictly confidential and kept according to the Data Protection Act.

REGISTRATION FORM

Name

Surname

Email Address

Phone

How did you find out about The BeingWell and this course?

Can you commit (as far as you know) to doing the full programme?

Please briefly state what you interest is in doing this course.

Please briefly say a bit about any previous experienced you have had in mindfulness (none necessary for this course). Eg. Meditation, Tai Chi, yoga.

As the course includes some gentle stretching and movement, please include any information in relation to your health and wellbeing which will help to make the sessions enjoyable and comfortable for you.

Have you had any significant life events or changes in the last year? If so, please provide some brief details.

Have you had any mental ill-health within the last few years, including symptoms of stress, anxiety or depression?

Have you ever been seen by a psychiatrist? If so, please give brief details.

Are you currently on any psychiatric medication? If so, please give brief details.

Please provide the name and address of your GP.

Please provide details of your next of kin in case of any emergency.

Is there anything else that you would like to make your mindfulness teacher aware of?

What is your date of birth?