MBSR Pre Course Form

The information provided from these questions is personal and sensitive in nature. I respect this and please be assured that it will be held strictest confidence only for your duration in the course. The information provided is to assess where this is an appropriate time for you to take the course.

Name

First Name

Last Name

Have you previous experience of Mindfulness/ Meditation/ Retreats?

Do you have any difficulties that make sitting, standing, walking or doing simple yoga movements challenging for you? If yes, please give details.

Are you presently on any medication I need to be aware that might affect you in the class? Eg For Epilepsy, Diabetes, Vertigo etc.

Are you been treated for any mental or psychological difficulties at present or have done in the past 6 months ? Anxiety, Depression, Burnout, Stress?

Have you had any significant life changing experiences in the past year? Ie. death of someone close to you, change in personal circumstance, break up of a relationship, change of job etc?

What are your biggest stressors right now?

Do you have a good support network in place for yourself? Friends, Family, Supervision, Therapist?

What brings you joy in your life?

What would you like to learn from the course?

Why are you taking the course at this particular time in your life?

NOTE: It is very important that you take good care of yourself during the course. If you have any difficulty with any of the exercises , you can stop for a while and carry on when you are ready. You are always welcome to talk to me if you have any questions that you may not wish to ask in the larger group.

I look forward to meeting you soon :)

- Clodagh