Mindfulness Course intake form

Please take a few moments to fill in the form below. You’ll have a chance to discuss further or ask any questions on our follow-up call.

Name

First Name

Last Name

Phone number

Address

(So that we can post you a course manual)

Emergency contact

Name and phone number

How did you hear about the course?

Do you have any experience of meditation or mindfulness?

As part of the course we encourage participants to dedicate time to a guided home practice of ideally about 30 to 45 minutes each day. Is this something you could make time for?

Do you have any physical, mental or emotional issues or conditions that you think might be relevant?

Do you have any supportive practices at the moment (e.g. coaching, therapy, yoga, etc)

What would you like to get out of the course?

Mindfulness Course intake form

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