Thank you for completing this form to help us get a better understanding of your current circumstances. Please note, this questionnaire is fully confidential.

Once we have reviewed your questionnaire we may need to arrange a follow-up call. Please add as much information as possible. If we do not have enough information, a call may be required.


First Name
Last Name
Street Address - Please use the address you will be at when completing the majority of the course or session.
Phone Number
Marital / Civil Partner Status
Emergency Contact or GP - Please include a name and contact telephone number.
Course / Retreat Title & Date
How did you hear about us?
What are your main reasons for joining? What are your expectations regarding the outcome of the course or session?
Please describe any previous experience you have with mindfulness meditation, mindful self-compassion or any other type of meditation.
Are you currently experiencing symptoms of or receiving therapy for any mental health conditions? Please also note any past history of mental health concerns.
Are there any particularly stressful aspects of your life at present? (e.g. work, finances, housing, family, relationships.)In addition to the scheduled course sessions, there is up to 45 minutes of home practice per day as part of the course, so we would like to be aware of anything that could interfere with your ability to develop a regular practice and/or attend the sessions.
Do you have any medical conditions or injuries that would limit your ability to practise gentle yoga-like stretching?
Do you have a professional interest in mindfulness? For example, learning to teach or using learnt skills in a clinical practice. If yes, please tell us more to support you in your experience.
Please detail anything else you think the teacher should be aware of?