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 GDPR, 2018. 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.Name(Required) First Name Last Name Email(Required) Phone(Required)Do you know anything about mindfulness? Please give details.(Required)What is your main reason for wishing to participate in this Course?(Required)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 have any concerns about your wellbeing which you would like to discuss with me prior to commencing the course please contact me.Between sessions there is an expectation that you do guided home practices plus additional short exercises and strategies. Do you have time for this?(Required) Yes No Do you have any difficulties that I need to know about so that I can support your learning? Pain Mobility Props to make you more comfortable Supportive chair required Hard of hearing Interpreter required Mental Health Concerns Trauma triggers Other Please give details if applicable.Do you have any questions of any sort or is there anything else I can help you with to support your attendance on the Course?Do you consent to your image or feedback being used in our publicity materials?(Required) Yes No Photos, videos, and feedback or testimonials are a good way for us to increase awareness of mindfulness and compassion and they are often taken or captured during teaching sessions and related events. We use this content gathered in publicity materials including printed and online publications, promotional videos, website and social media, PR, promotional materials and advertising. Please choose whether or not you consent to your image or feedback being used. Δ