Application Form

Two-Day Inquiry Workshop – 03/05/2019 – 04/05/2019


Terms & Conditions

We never share your information. However, we occasionally send news updates and information to delegates about our forthcoming courses and events. If you would rather not receive this information, please tick the box.
I confirm by ticking this box that I have read the course description and relevant information sheets and understand and agree to the payment and cancellation arrangements of the Mindfulness Network.
About you
Title:
Forename:
Surname:
Address 1:
Address 2:
Address 3:
County:
Postcode:
Country:
Phone:
E-mail:
DOB:

 

Where did you find out about this course?

Please state:

Your physical health
Please provide the name of your GP:
Please provide the address of your GP:

Please provide the phone number of your GP:
Do you have any current medical conditions?
Please provide further details of your current medical conditions:
Do you have any physical illness or other limitation that may make hearing, sitting, standing, walking or doing simple exercises difficult for you?

Please provide further information about your physical illness/limitation:
If you have significant physical health problems, please tell your GP that you are undertaking the course.

Your mental health
Have you had any mental health issues or concerns within the last few years, such as anxiety or depression?

Please provide further information regarding mental health issues or concerns:

Are you taking any medications or over-the-counter drugs at the moment?

Please list your medications here:

Have you ever received psychiatric or psychological treatment before?

Please provide further information regarding psychiatric or psychological treatment received:

Have you ever made a suicide attempt?

Please provide further information:

If you are currently receiving counselling, psychotherapy or any mental health treatment please tell your therapist that you are undertaking the course.

Alcohol and other substance abuse
Has alcohol or drug use (including over-use of prescribed medication) ever caused problems for you?

Please provide further information:

Experiences of upsetting events
Sometimes things happen to people that are extremely upsetting – things like being in a life threatening situation like a major disaster, very serious accident or fire; being physically assaulted or raped; seeing another person killed, dead, or badly hurt, or hearing about something horrible that has happened to someone you are close to. At any time during your life, have any of these kinds of things happened to you?

Please provide further information:

Sometimes these things keep coming back in nightmares, flashbacks, thoughts that you can’t get rid of. Does this happen to you?

Please provide further details:

Do you ever get upset when you are in a situation that reminds you of one of these terrible things?

Please provide further details:

Course fees
Our rates have no hidden extras and include teaching and deposit (if applicable). Our residential events also include accommodation, room and board.

You can choose to pay the entire amount for this retreat or just the deposit. However, if your application is within 4 months, then you will be invoiced for the full amount for the retreat. If you have paid a deposit, 4 months before the retreat date you will be invoiced for the balance which must be paid within 30 days.
Please select the fee that you’re paying.

Is your fee to be paid by your employer?

Employer name:

Employer’s address:

Employer’s postcode:

Contact name at employer:

Contact e-mail address at employer:

Contact phone number at employer:

Do you have a purchase order number – if you are working within the NHS, this is usually necessary:

Other
When, where and with whom did you do an 8-week MBSR/MBCT course?

Describe your mindfulness practice; what it is and how long you have been practicing?

Details of any training you have had to teach the MBSR/MBCT course or other mindfulness-based interventions.

Approximate number of MBSR/ MBCT courses you have taught?

What is your professional role / work?

What has drawn you to this course?

Please give details of any previous mindfulness courses, and/or training you have attended.

Please indicate briefly what you hope to get from this event.

Any other information you would like to pass onto the admin team or teachers in connection with this application: