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Teaching Mindfulness
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8-Week Mindfulness-Based Stress Reduction MBSR Application form
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I confirm by ticking this box that I have read the course description and understand and agree to the payment and cancellation arrangements of Mindful Academy International. Terms and conditions can be found at https://mindfulacademyint.com/terms-and-conditions/
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Please enter the telephone number and name of the person we can contact in the event of an emergency.
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Where did you hear about the course?
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Do you have any current medical conditions?
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If yes, please give details here. This information is confidential and will only be shared with the Teacher to ensure that it is the right time for you to take the course.
Do you have any physical illness or other limitation that may make hearing, sitting, standing, walking or doing simple exercises difficult for you?
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Have you had any mental health issues or concerns within the last few years, such as anxiety or depression?
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No
Have you ever received psychiatric or psychological treatment before?
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Yes
No
Have you ever made a suicide attempt?
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Yes
No
If you are currently receiving counselling, psychotherapy or any mental health treatment please tell your therapist that you are undertaking the course.
Has alcohol or drug use (including over-use of prescribed medication) ever caused problems for you?
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Sometimes things happen to people that are extremely upsetting - things like being in a life threatening situation like a major disaster, very serious accident or fire; being physically assaulted or raped; seeing another person killed, dead, or badly hurt, or hearing about something horrible that has happened to someone you are close to. At any time during your life, have any of these kinds of things happened to you?
Yes
No
Which 8-Week course are you applying for?
Private 1-1 Mindfulness-Based Stress Reduction MBSR course
Private 1-1 Mindfulness-Based Cognitive Therapy MBCT for chronic illness course
Private 1-1 Mindfulness-Based Cognitive Therapy MBCT for cancer course
Please give details of what you hope to learn from this course
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