Client Information
MBCT 2023
Full Name
*
First Name
Last Name
How would you like to be addressed?
Date of Birth
*
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Day
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Month
Year
Occupation
Telephone
*
E-mail
*
Contact In Case of Emergency
*
Name
*
Telephone
*
Relationship
How did you hear about the MBCT programme?
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Friends
Hope for Tomorrow client
Google
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Others (please specify below)
If you choose "others" for the above question, do let us know how you found out about the MBCT programme.
What are your main reasons/motivation for wanting to participate in the MBCT programme?
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Health Questions
The health information you provide is used to help us assess if the course is safe and beneficial for you. Information is kept confidential and only available to the mindfulness instructors who will contact you for further discussion before starting the course. Please speak to us too if you have any concern about the suitability of the course for you.
Do you have Diabetes Type 1?
Yes
No
Do you have any physical or sensory limitations that may affect your participation (e.g. make certain postures or gentle stretching movements difficult)?
Yes
No
Are you currently receiving any psychiatric or psychological treatments?
Yes
No
Have you experienced psychotic episode/s in the past?
Yes
No
Have you experienced a manic/hypomanic episode in the past 6 months?
Yes
No
Have you deliberately harmed yourself in the past year?
Yes
No
Have you ever attempted to take your own life?
Yes
No
Have you ever experienced a traumatic event which is currently affecting you?
Yes
No
Are there any recent life events (e.g. loss of job, relationship breakdown, bereavement, too many work commitments etc.) that may be placing you under additional stress?
Yes
No
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