Registration and consent form for Mindfulness Based Stress Reduction
This form is required to register for MBSR and the Introduction to Mindfulness course. It is necessary for us to ask you a few questions to complete your registration, and to check that it is safe for you to participate in this course. If you have any problems completing the form, please feel free to contact us directly or on 83735655 during business hours.

Before proceeding with your registration, please read the following document to make sure the course and the timing is right for you.

Which upcoming course/classes would you like to register for? *
Contact details *
Please type your full name here
Your answer
What is the best contact number for us to ring you on during business hours?
Please also make note of the best time to contact you to confirm registration
Your answer
What is your email address?
Your answer
How did you find out about the programme?
If you have been referred, please include the details of your referrer (GP, psychiatrist, friend etc).
Your answer
Medical Health
The following confidential information is required in order for us to determine the programme's suitability for you at this time, and to best look after you during the classes. Your instructor may contact you prior to starting the programme to discuss any relevant issues. I give permission for this and to contact my GP if required.
Do you have Diabetes Type 1?
Do you have any current or previous medical conditions of physical injuries that I need to be aware of? *
Your answer
Current treatment (if any)
Your answer
Have you experienced depression in the past 6 months? *
Are you currently experiencing depression? *
Are you currently receiving any psychiatric or psychological treatments? *
Are you currently taking any medication? *
Have you ever experienced a severely traumatic event which is currently affecting you? *
Have you experienced bereavement in the past year? *
Are there any current life changes (loss of home, job, relationship breakdown, too many work commitments etc.) that may be placing you under additional stress? *
Your answer
What do you hope to gain by attending the course? What are your main intentions? *
Your answer
Payment options : $750
The recordings for the home practice meditations are provided via MP3 download (link emailed to you). Do you need any help with this option?
Thank you
We will be in touch with more detail about where to go and what to bring! Any questions, please feel free to ask here:
Your answer
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