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.
On a scale of 1-10 how stressed have you felt in the last fortnight (10 = Extremely stressed / 0 = Not at all). Please explain why you have given this response.
What are the most stressful aspects of your life currently? For example, work, finances, housing, family, relationships. Please provide as much detail as possible.
For those completing a course, in addition to the scheduled sessions, there is up to 45 minutes of home practice per day. We would like to be aware of anything that could interfere with your ability to develop a regular practice and / or attend the sessions. In advance of the course, please consider how you will set aside time and space aside to practise.
Learning mindfulness or mindful self-compassion can bring up strong emotions. What support do you have in your life if needed, in addition to the resources of the course and teacher? For example, friends, pastoral care, mental health professionals, etc.
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 note, as a matter of policy, we ask that anyone interested in pursuing mindfulness from a professional standpoint put aside such interests for the duration of the course to practise for their own well-being. If you have any concerns or questions about how that might impact your experience, please contact
Please detail anything else you think the teacher should be aware of?
Finally, as part of the Terms & Conditions you signed up to when booking, we would like to draw your attention to our Participant Agreement. In submitting this questionnaire, you agree that you have read the Participant Agreement in full and commit to the requirements outlined.
If you have any questions about this or anything else, please email