MBSR Application form
Name *
Your answer
Address *
Your answer
Phone number *
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Email address *
Your answer
Date of Birth *
Your answer
Occupation *
Your answer
Date of MBSR programme you wish to attend *
Your answer
Reasons for attending and your expectations *
Your answer
Any previous experience with meditation /mindful movement/yoga? if yes please give details
Your answer
Any physical, mental or emotional difficulties that you would like me to be aware of? If yes please give details
Your answer
Current state of health and wellbeing *
Your answer
Any current medication? if yes give details
Your answer
How did you hear about the course? *
Your answer
Any other information you think would be important for me to know?
Your answer
Feelings of sadness, anger, fear could seem stronger at the beginning because you may be paying attention in a conscious way for the first time. A history of trauma, abuse or addiction to substances may heighten these reactions. Please tell me if this is true for you and we can determine together whether or not it makes sense for you to take this class at this time.
Your answer
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