Mindfulness-Based Stress Reduction Course Application Form

Mindfulness-Based Stress Reduction Course Application Form

To help the instructors, please complete the following form as fully as you can. The information given is strictly confidential and will be seen only by the instructors. After the course, this information will be destroyed.

Please ensure you have read the information about the course and are aware of the level of commitment involved in taking part. Please consider carefully whether you are able to commit sufficiently to the programme and that this is the right time to undertake it. To gain maximum benefits, you will be required to practise at home.

Should you experience any difficulties during the course, it is important that you inform the instructors so that they can address any specific needs you may have and guide you more effectively. Please also realise that you need to take responsibility for yourself and seek your own appropriate support if necessary.

If you are unsure about any aspect of the form, please do not let this put you off applying. Just fill it out as fully as you can, ensuring you enter your contact details, and an instructor will contact you to discuss your application. Participants will not be able to join the course without completing the form and/or talking to an instructor first.

ABOUT YOU

Which course dates are you applying for? (Please mark with an “X”)

1. Do you have any physical difficulties that make sitting, standing, walking or doing any simple exercises difficult for you? If yes, please tell us about them.

2. Have you had any health problems in recent years, e.g. anxiety or depression? If yes, please tell us about it here.

3. Are you currently taking any medication? If so, please say what it is and what it is for.

COURSE COMMITMENT

4. A commitment to attending all classes and the practice day is very important. Are there any dates you know in advance which you will be unable to attend?

5. Are you able to commit to practise at home?

IS THIS THE RIGHT TIME FOR YOU?

6. Are you currently dealing with any major issues in your life (e.g. moving home, changing jobs etc), which may affect your ability to participate fully in the course? If so, an instructor will be very happy to contact you.

7. Consider who can support and encourage you while you are doing the course.

8. Is there anything else you think it would be helpful for the instructors to be aware of?

9. Please help us by telling us where you heard about the course?

YOUR GP DETAILS (Optional)

GP Name:

GP Address and phone number:

I give consent to contact my GP in an emergency. Yes/No. (Delete as appropriate)

If you would like to ask any questions before completing this form, please feel free to e-mail us and request that an instructor contact you. Please state preferred contact number(s) and time(s) when it is best to call.

Please return your completed application form to:

MBSR Course Applications

The London Mindfulness Centre

c/o Courthouse Community Centre

43 Renfrew Road

London SE11 4NA

or e-mail Vinod/Jane:

Many thanks and we look forward to hearing from you and to welcoming on to the MBSR course.

All good wishes

Community Team