Course Details:
8 Week Mindfulness Course
Wednesday 3/10/17/24th May, 7/14/21/28th June 2017 (4.15pm-5.45pm)
Day retreat at Chalfont St Peter Academy (10am-4.00pm) on Sunday 18th June 2017

Your Details:

Name (required)

Telephone (required)

Email (required)

Address

Postcode

Year of Birth

Occupation

Please tell me how you heard about the course (if by internet please specify which site):

Health Questionnaire:

To help me guide you on this course, please complete this health questionnaire. The information you give is strictly confidential and will only be seen by the course facilitators 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)

If you have had any previous experience of mindfulness of meditation please tell me about it here:

Please tell me about your reasons for booking onto this course:

The facilitator reserves the right to cancel the course under any circumstances. Should this be the case you will receive a full refund.

I understand that in some cases, for unforeseen reasons, participants cannot avoid missing a session of the course. It is not possible to make up missed sessions by transferring to another course at a later date or to receive a refund if you do not complete the course. It is also not possible to join any course without being able to attend the first session of the course in full.

Signed:

Date:

If you have any queries about this form, or the course, please contact Gayle Creasey on 07941 279177

By using this form you agree with the storage and handling of your data by this website.