Course Details: Mindful Self-Compassion Retreat Day Saturday 12th August 2017 (10m-4pm) Your Details: Name (required) Telephone (required) Email (required) Address Postcode Year of Birth Occupation Payment: Course Cost: £75 Full Payment is required at time of booking to secure your place. Bank transfer (payable to: Co-operative Bank A/c 12306145 S/c 089103). Please ensure you put your name and MSC RETREAT in the reference box so your payment can be identified. Health Questionnaire: To help me guide you in this group, please complete this health questionnaire. The information you give is strictly confidential and will only be seen by the course facilitator. If brought to the facilitator’s supervision, it will done so anonymously. No information is held long term on any data base and all forms will be destroyed after the course. If you have any physical illness or other limitation that may make sitting, standing, walking or doing simple exercise difficult, please tell me about it here: If you have had any mental ill health within the last few years, such as anxiety or depression, please tell me about it here: If you are taking any medication at present please say what it is and what it is for: If you are going through any significant life events at the moment please briefly say what they are (eg. moving home, loss of job, relationship issues or divorce, bereavement) Please give a brief overview of your previous experience of mindfulness or meditation here: Please tell me about your reasons for booking: Booking Conditions: The following proportion of your fee, less a £20 admin charge, will be refundable if you cancel your place: Up to 2 months before the start date: 100% Less than 4 weeks before the start date no refund will be made. The facilitator reserves the right to cancel the course under any circumstances. Should this be the case you will receive a full refund. Signed: Date: If you have any queries about this form, or the group, please contact Gayle Creasey on 07941 279177 By using this form you agree with the storage and handling of your data by this website.