MBSR Application Form

Thank you for your interest in my next MBSR course.

Given the nature of the training course, it is best practice that we complete a pre-course conversation and application process so we can mutually agree that this is the best course for you right now.

Please fill in this form and there will be space to let me know when is a good time to schedule a call to go through the information in more detail. If you have any questions before or after completion, please feel free to get in touch directly. Please be assured all information received is in strictest of confidence and maintained in line with GDPR (2018).

Many thanks and I look forward to speaking with you in person soon, Sheena.

1. CONSENT

This course is a non-residential group course. It is an intensive introduction course. You are completing this application form to provide essential contact and background information and so that we may mutually consider your suitability for taking the course at this time in your life.

There are 4 sections to complete: 1. Consent 2. Contact Details 3. Health & Living 4. Last Words

We will discuss the details during a pre-course conversation. By completing and submitting this form you are agreeing to Sheena Burke storing this information on a secure system. This information is shared only for the duration of the course. At the end of the course this information will be securely deleted. If you do not participate in the course, your details will be securely deleted. No details are shared with any third-party.

Full payment is required in advance of the course start date. A booking deposit secures a place, pending successful completion of the application.The balance is paid using bank transfer upon confirmation of your place and by the start date of the course. All deposits are non-refundable. Refunds of the balance of course fees may be offered if bookings are cancelled 7 days prior to the course date. Cancellations less than 7 days before the start date are not refunded but may be agreed to transfer to another course. See http://www.discoveringmindfulness.ie/terms-conditions/ for more details.

YesNo

2. CONTACT DETAILS - About Me

Name

First NameLast Name

Date of Birth

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you learn about this course?

What draws you to the course at this time?

3. HEALTH & LIVING

Please describe your general health

Do you have any medical conditions or physical health needs at present. Please give detail including any treatment.

Do you have any physical needs that may make hearing, seeing, sitting, standing, walking, lying down or doing simple movements, difficult for you? If yes, please give details.

Have you experienced any mental health difficulties or illness to date? If yes, please offer brief detail. For example, anxiety, depression etc.

Have you received past and current psychological or psychiatric treatment? If yes, please give brief detail.

Have you made a suicide attempt in the past?

Has alcohol or drug use (including overuse of prescription medication) caused difficulties for you? In what way?

Sometimes we experience life events or moments as extremely upsetting - maybe being in a life threatening situation like a major disaster, very serious accident or fire; being assaulted, seeing or hearing about something very distressing that has happened to someone you are close to. Have you experienced any distressing responses to life events that have significantly impacted your life - past or present? If yes, please offer brief detail as you can.

What do you do to help with managing stress and difficulties?

Do you have a key person or support network of friends, family and/or health care professionals?

In case of emergency contact: Please provide a name and telephone number of who I may contact in the event of an emergency that may arise.

4. LAST WORDS

Is there any other information you would like to share at this stage? Or questions you would like to bring to our pre-course conversation?

Type a question

Please say what day and time is best to schedule the pre-course conversation.

Liabilty Waiver

By submitting this form, I hereby retain Sheena Burke as my teacher for this MBSR online course.

In participating in this course, I accept full responsibility for performing only those activities and moments that support and do not jeopardise my health and well-being. I understand that the course curriculum may carry a risk of injury as does all activity and sign this retainer and liability waiver in agreement that Sheena Burke ( and venue/videoconferencing application used) are not responsible for any loss, damage or injuries.

I understand that Sheena Burke is providing training, coaching, feedback and support in assisting me to become aware of my body’s inner wisdom. My role at all times is to be awake to the message my body is sending me and to avoid any activity or movement that may cause pain.

I understand that Sheena Burke is not diagnosing, prescribing or treating. I agree to consult my General Practitioner about any concern I have about a state of illness, dysfunction or pain and to advise Sheena Burke about such concerns.

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Please note that if you are taking the online course - it is important for you to be able to

find a quiet place

free of distractions for your call

advising friends and family that you are not to be disturbed.

This means that you will be able to focus on the direct experience of Mindfulness, and make the most of our time together.

To take part in the group Zoom course and to ensure the best possible experience for all participants the course relies on video conferencing which has minimum requirements to work properly. That includes having a computer with speakers, microphone, video capabilities, and a high speed internet connection (not Wi-Fi). There is more information and links to tutorials about Zoom that can help you prepare. You need only basic computer skills to take part.

Thank you and I look forward to speaking with you soon!

Sheena

sheena@discoveringmindfulness.ie