Mindfulness-Application-Form

Mindfulness Application Form

* Indicates required field

Name *

First

Last

Date of Birth: *

Occupation: *

Email *

Phone Number *

Part Two: Lifestyle/Medical Checklist:

1.What are your main stressors/challenges at present? *

2. Is there a particular challenge in your life at the moment and if so, how is this affecting you in daily life? * *

3. Do you have any preexisting medical conditions or are you taking any medications you feel might be useful for me to know? *

4. Are you under the supervision of a mental healthcare professional at the moment? *

5. Have any major life events occurred over the past six months that might be useful for me to be aware of? *

6. Do you have anyone that is supporting you? Family, Friends, Counsellor? *

Part Three: Self-Reflection

7. Do you have any previous experience with Mindfulness & Meditation? *

8. What is your main reason for taking this programme at this time? What brings you here at this point in your life? *

9. What brings you joy in your life? *

10. What are your greatest worries? *

11. How would you know at the end of this programme that it had been worthwhile taking? *

12. How did you hear about this programme? *

13. Take a moment to consider how much time you can give to daily Audio Meditation at the moment? 10, 15, 20 or 30 minutes? *

14. Please provide any further information you feel might be helpful for me to be aware of. *

Many thanks, Freada
Freada McGoldrick, Mindfulness Based Stress Reduction Teacher, University of Massachusetts Medical Dept. Somatic Movement Educator. MythoSelf(r)Process Trainer with Applied Behavioural Technologies.

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