First Name

Last Name

Street Address

Phone Number

Email

Age

Marital / Civil Partner Status

Occupation

Emergency Contact or GP (Name and Number)

Course Start Date

How did you hear about the course?

What are your main reasons for wanting to take this course? And what are your expectations regarding the course outcomes?

Please describe any previous experience you have with mindfulness meditation 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 practice gentle yoga-like stretching?

Is there anything else you would like the course teacher to be aware of?