SIT Registration April 2020
The following information is strictly for the confidential use of the course teacher, Susie Jones. Please answer these questions fully to enable her to guide you appropriately. Disclosure of any physical/psychological history will not necessarily prevent you from undertaking a mindfulness course.
Name (first name + surname) *
Your answer
Email address *
Your answer
How did you hear about this course?
Do you have any history of physical illness or any disabilities, which may significantly affect your sitting, standing, or walking practice?
Your answer
Have you ever been diagnosed with or experienced any significant mental health issues, e.g. depression, eating disorders, anxiety, trauma, drug/alcohol abuse? If yes, please give details of condition(s) and date(s).
Your answer
Describe any present circumstances that might place you under additional stress or may significantly affect your meditation practice (e.g. bereavement, redundancy, relationship breakdown, etc.)
Your answer
Is there any additional information you would like to convey to the teacher?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy