Mindfulness 4-week Programme 2022

This form will take approximately 10 minutes to complete.

Thank you for taking the time to fill out the form. Your honest sharing will allow the teacher to better understand and support you during the course of the programme.

We understand the personal nature of these questions. Please be assured that the completed forms are kept in strict confidence.

Past MBSR/MBCT Graduate *

Yes No

Participant Details

Name *

E-mail *

Contact No. *

Mailing Address *

What is your main reason for participating in this programme *

Occupation *

Birthdate *

Day Month Year

Gender *

Marital Status *

Do you have children? *

Yes No

a. How many? *

b. What are their ages? *

Do you have close friends? *

Yes No

Sleep quality *

average no. of hours per day

Do you smoke? *

Yes No

Caffeinated drinks per day *

Do you exercise? *

Yes No

Do you use alcohol? *

Yes No

How much? *

Do you take prescription medications? *

please list

Are you currently engaged in psychotherapy? *

If no, have you been in therapy during the last three years? *

During the last MONTH, you have: *

considered suicide sought psychiatric help had urges to beat, injure or harm someone had urges to smash or break things had spells of terror or panic none of the above

Please take a moment as you respond to the following three questions.

1. What do you care about most? *

2. What gives you the most pleasure in life? *

3. What are your greatest worries? *

Please list three personal goals you have for taking the Mindfulness-Based Stress Reduction Programme?

Personal Goal 1 *

Personal Goal 2 *

Emergency Contact Person *

Emergency Contact Phone No. *

Terms and Conditions

1. Registration and Payment

Places are allocated on a first-come-first serve basis and will be confirmed on receipt of payment of the programme fee and the registration form.

2. Cancellation & Missed Class Policy

a) A no refund policy applies. For pre-determined, medical and psychological issues that may render the participant unable to complete the course, the withdrawal will be considered on a case-by-case basis.

b) The Open Centre reserves the right to cancel a programme due to insufficient members. Participants will be notified at least 7 days prior to the commencement of the programme and a full refund of the programme fee will be provided.

c) We make all effort to ensure there are no changes in terms of location, times or teacher. In the case of unanticipated conflicts, a suitable replacement option will be offered. No refunds will be made in such cases. We will inform you by email or phone of the change as soon as possible.

3. Liability

The Open Centre does not accept liability for personal injury or the death of any participant unless directly caused by the proven negligence of the company.

In case of any dispute, The Open Centre reserves the right to exercise final discretion.

*

I have read the terms and conditions of enrolment. Checking this option indicates my understanding and agreement.

*

I have provided The Open Centre (S) Pte Ltd with all the information necessary for the centre to provide reasonable support during the duration of the programme.

The risks, benefits and possible side effects of the Stress Reduction Programme were explained to me. This includes skill training in meditation methods as well as gentle stretching (yoga) exercises. I understand that if for any reason I am unable to, or think it unwise to engage in these techniques and exercises either during the weekly sessions at TOC or at home, I am under no obligation to engage in these techniques nor will I hold the above named facility liable for any injury incurred from these exercises.

Furthermore, I understand that I am expected to attend each of the eight (8) weekly sessions, the daylong session and to practice the home assignments for 40-60 minutes per day during the duration of the programme.

Name *

Signature (Click and hold inside the box to sign) *

Clear

Date *

Day Month Year

Calculation

Programme Dates *

9 Apr - 28 May 2020 $ 180.00 SGD

Enter coupon

Total $ 0.00 SGD

4-Week Mindfulness Programme 2022 Registration Form

Mindfulness Programme @ The Open Centre