Application

Name:- ………..

Contact email:-………..

Telephone:-…………

Dat of birth:-…..

Occupation:…….

How did you hear about Shere Mindfulness?………..

Main reason for wanting to participate in this course?……..

Previous knowledge or experience of Mindfulness? If so, please give details……

Assessment

Are you receiving therapy or any kind? If so please give details……..

Are you taking any medication? If so please give details…..

Have you received hospital treatment in the past two years? If so, please give details……

Do you have any physical or mental health issues at the moment? If so, please give details…..

Do you suffer from any physical pain? If so, please give details…..

Do you drink alcohol? 

1. Occasionally

2. Every day

3. Not at all

Do you take any recreational drugs?

1. Occasionally

2. Every day

   1. Not at all

   Do you smoke?

   1. Occasionally

   2. Every day 

   3. Not at all

   Do you drink caffeine?

   1. Moderately

   2. Excessively 

   3. Not at all

   Do you do any physical exercise? If so please give details…..

   Are you able and willing to give over at least 40 minutes per day to formal and informal practices?…..

   Consent

   Thank you for filling out this form. Please be assured that the details you provide will be kept in strict confidence adhering to the General Data Protection Regulation (GDPR) 2018. The only exception would be if you or someone else was at risk. On completion of the course, the information will be disposed of from my records.

   All the information I (the client) have provided is true on the date given.

   Date:-

   Signed by client:-

   Signed by teacher:-