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MINDFULNESS COURSE APPLICATION FORM

Personal Information

Birthday

Health Questions

The health declaration information you provide is used to assess your suitability for this course. It is kept as confidential and is only available to the course practitioner and where necessary their supervisor. On submitting this form the practitioner who need to contact you for further discussion.

"I undertake to be responsible for my own wellbeing during the course and agree to bring any concerns to the course teachers in the first instance, and contact my GP or relevant health professional, should I continue to have concerns about my wellbeing."

Do you have a physical or sensory limitation which may affect your participation?
Yes
No
Do you have Diabetes Type 1?
Have you experienced depression in the past 6 months?
Are you currently experiencing depression?
Have you ever experienced a psychotic episode/s in the past?
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