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Booking Form – 8 Week Mindfulness Based Living Course (MBLC)

Venue / Tick Venue
Cardiff / Caerphilly
Start Date

Addresses for our Centres:

Cardiff: 250 Cowbridge Road East, Canton, Cardiff, CF5 1GZ

Caerphilly: 2a-4a Cardiff Road, Caerphilly, CF83 1JN

Contact Details
Name / Email
Address / Mobile
Landline

Your details will be kept on file for course administration purposes. If you would like to join our mailing list, please tick the box below for the types of email you’re happy to receive.

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Courses and Events / Thought for the Day / Volunteering

How did you hear about the course (tick all that apply)?

Facebook / Google / Email / Poster
Friend / Colleague / Therapist / Work

Other (please specify):

If you are currently suffering from or being treated for any Mental Health condition, please specify:

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We would like to emphasise that this Mindfulness training is not a treatment for mental health problems. If you have recently received or are currently receiving treatment from a psychiatrist, psychotherapist or counsellor for an ongoing mental health problem, we strongly advise that you obtain approval from your mental health professional before proceeding further with this training at this time. Also, if you have recently or are currently going through a traumatic life event such as a separation from a long term partner, the death of a close family member or friend or redundancy this may not be the right time for you to continue with this training. This very much depends on your current psychological health and the support networks that you have around you, such as friends, family and mental health professionals. For anyone withdrawing from the training for these reasons, the option is available to you to take up the training next year or in future years.

If you are currently taking medication for a mental health problem, then we recommend that you do not change your medication, other than in close collaboration with your medication prescriber.

If any of these circumstances apply to you, then we recommend that if you have not done so already, you contact one of the tutor team to discuss your situation and the support networks you have in place and explore how we can best support you going forward.

Please tick this box to indicate that you have read and understood this statement □

Please fill in second page as well

Accessibility

Mindfulness courses in Cardiff are taught on our ground floor where there is a wheelchair accessible toilet. We have a portable ramp to allow access in Cardiff. Retreats are usually held in our Caerphilly centre which is up a flight of stairs.

Therefore, please notify us when you return this form should you require wheelchair access or have other mobility restrictions, please notify us when you return this form. We will then arrange for the retreat to be held elsewhere to allow for access.

Course Fee options

£180 in full in advance / £200 including £50 non-refundable deposit

Please use reference “8weekM” and your name when paying by bank transfer.

Payment Method

Cash / Cheque / Bank Transfer / Paypal/Website

Account name: Samye Foundation Wales

Account no: 65216868

Sort Code: 08-92-99

Cheques must be made payable to Samye Foundation Wales.

Cancellation Policy

1 Month notice – full refund

2 Weeks’ notice – 50% refund

Less than 1 week notice – no refund

We must have notice received before the start of any course in order for a refund to be made.

Please tick to show that you have read and understood these terms and conditions.

Signature: …………………………………. Date: …………………………

For more details or if you require a standing order form, please contact:

For the courses provided and run by our centre we ask participants to pay a suggested contribution. However concessionary prices are offered for students, pensioners, the unemployed etc. and any lack of funds should not prevent anyone from attending our courses.

For concessions and other questions about prices please call our office on 02920 228 040 or email us on

Samye Foundation Wales is a registered charity, number 1122144 Registered company, number 05901855(limited by guarantee)