Mindfulness Course Form Web Site First Name * Last Name * Age Mobile Number * Email Address * Start date of course What are your reasons for attending the course? What do you hope to get out of it? * What do you think Mindfulness is? Have you any previous experience? * Do you feel it is possible for you to put aside up to 30mins of home practice most days during the course? * Yes No Have you had any significant life events, bereavements or traumas in the past year? If yes, please also confirm if you feel now is the right time for Mindfulness. * Do you have any concerns or questions about the course? To help me guide you most effectively on the course, it would be very helpful if you would answer the following questions where appropriate. The information you provide is strictly confidential. – 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: – If you have had any mental ill-health within the last few years, such as anxiety or depression, please tell us about it here: – If you are taking any medication at present, please say what it is and what it is for: I understand that this mindfulness course is taught for educational purposes only. If I am suffering from a medical condition, I have checked with my doctor/health professional that this course is suitable for me. * Yes No Any further comments or questions?
