Registration and consent form for Mindfulness Based Stress Reduction
This form is required to register for MBSR. 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.

Email address *
Which upcoming course/classes would you like to register for? *
Name *
Please type your full name here
Your answer
Date of birth *
Address *
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
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 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? If yes, please list below: *
Your answer
Have you ever experienced a traumatic event which may be currently affecting you? *
Have you experienced bereavement in the past year? *
Are there any current major life changes (loss of home, job, relationship breakdown, too many work commitments etc.) that may be make it difficult to focus on the course and home practice? *
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 a free App. We can help you set this up when you come in for your pre-course assessment if needed?
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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