Assessment Form (MBSR)

Thank you for filling out this form. We realise the personal nature of these questions and please be assured that they are kept in strict confidence adhering to the current GDPR. The data will be kept for the duration of the course. On completion of the course you may request that the information be returned to you or disposed of from our records.

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Name
First Last
Email
Phone
Organisation
Course Start Date
Do you know anything about Mindfulness?
Please give details
What is your main reason for wishing to participate in this Course?
Although this is not a therapy group it is helpful to know if there any significant personal issues going on in your life.
If you become upset during sessions, as the teacher I encourage my students to create some space, switch off their camera and use their breath as an anchor to focus attention. How else would you like to be supported?
Between sessions there is an expectation that you do guided home practices for 30 minutes per day plus additional short exercises and strategies.
- Yes
- No
When and where would that be?
Thank you for filling out this form. Your tutor may contact you directly prior to Course commencement via telephone and ask or answer any more specific, personal questions, if required.

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