MBCT Course Registration Form - Community
Thank you for your interest in this course. The aim of the course is to promote cultivation of mindfulness. To ensure the course is suitable for you at this time, we need to ask some questions about your health and wellbeing. Please be assured that the information you provide will be treated confidentially. On receipt of this information I will arrange a telephone call to discuss further.
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PERSONAL INFORMATION
First Name *
Surname *
Course details *
Address *
Post Code *
Mobile Number *
Date of Birth *
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/
DD
/
YYYY
Gender *
Occupation *
Name and number of emergency contact *
How did you hear about the course? *
Do you have past meditation experience? *
What is your reason for registering for the course? (e.g. mental health, stress, physical health, personal development etc.) What do you hope to gain? *
Will you be able to attend all the sessions? *
Please indicate what day would be suitable to call you *
Please indicate what time would be suitable to speak to you. *
Specify a suitable date and time for you
ABOUT YOUR HEALTH
Do you have any physical conditions or limitations that might make sitting, standing, walking or gentle yoga difficult for you? If yes, please give details *
Do you have any mental health problems such as depression or anxiety? If yes, please give details *
Have you deliberately harmed yourself in the past? If yes please give details
Have you ever attempted to take your own life? If yes please give details
Are you currently taking any medication for any physical or psychological conditions? If yes, please give details
Are there any current circumstances which might be placing you under additional stress e.g. current depression, anxiety, psychotic illness, drug and/or alcohol dependency issues, stressful life changes (e.g. bereavement, relationship breakdown, loss of home, job etc)? If yes please give details *
Are there any health professionals involved in your care? Please give details
Do you have social support *
Is there anything else that we need to know that has not already been mentioned? If yes please give details *
TERMS AND CONDITIONS
The aim of this course is to promote awareness of your mind and body through the cultivation of mindful awareness. It is suitable for people wishing to enhance their general mental and physical well-being.
 
It is not suitable for people who are currently experiencing very severe problems in these areas. In the unlikely event that we do not believe the class suitable for you at this time, we will get in touch with you as soon as possible to explain why and process a full refund.
 
We are unable to take responsibility for any aspect of your health care, during or after the course and recommend that you contact your GP in the event of any deterioration in your health. You undertake to be responsible for your own well-being during the MBCT course.

You confirm that you are booking a place on the course for yourself and the details given pertain to you, that you are aged at least 18 and that you are happy for us to contact you before the class if we need to.
 
 
PAYMENT
 
Please remit payment as soon as possible. Your place is not secure until full payment has been made.

Please remit your payment to the following bank details

Dr Molefi
SANTANDER
ACCOUNT: 83047524
SORT CODE: 090128
REF: MINDFULNESS COURSE - FULL NAME

Your place is not secure until your payment has been received.

Dr Molefi will be in touch with you for a brief telephone interview once payment has been received.

Thank you.
 
 
DATA PROTECTION
 
By supplying personal information you are consenting to The Mindful GP holding and using it for the purposes for which it was provided. Information provided will be kept for as long as is necessary to fulfil that purpose. Personal information collected and/or processed by The Mindful GP is held in accordance with the provisions of the GDPR.

 
CANCELLATION POLICY
 
You may cancel your place up to 4 weeks before the course start date, but an administration fee of £30 administration fee will be applied.
 
We will not be able to give you a refund if you cancel your booking within 4 weeks of the course start date.

If, in exceptional circumstances, the teacher has to cancel leading a course/class etc, The Mindful GP will attempt to find an alternative presenter or an alternative date. If we cannot find an acceptable alternative for you, then your fees will be refunded. Our liability is limited to refund only The Mindful GP course fees. We recommend participants have adequate insurance to cover any cancelled travel or personal expenses.

TRANSFERS

Transfers to another one of our courses will only be considered if a minimum of 8 weeks notice is given. In addition, transfers will only be permissible if there is space in another course within 6 months of the originally booked course
I accept the terms and conditions as stated above *
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This form was created inside of Vital Wellness Clinic.