Mindfulness for Managing Pain and Long Term Conditions
Referral Information
Name
*
First Name
Last Name
OpenCRM Event
Contact email address
*
example@example.com
Contact telephone number
*
-
Area Code
Phone Number
Your postcode
*
What conditions do you have that have brought you to this course? If you are happy to share, this would be useful background for person leading the session.
*
Our course tutor may get in touch before a course to discuss any support you may need, please indicate if you are happy to be contacted.
Yes, I'm happy to be contacted
No, I'd rather not be contacted
Do you have any access or communication requirements which need to be met in order for you to engage fully, for example, support with any sensory impairments etc. If so, please give details.
*
To book onto a 90-minute Introductory Session, please select below:
*
Healthy Me Healthy Communities / Gorton Community Centre: 90-minute introduction to Mindfulness, Tuesday 31st January, 10am - 11.30am
To book onto a course, please choose below:
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Benchill Community Centre, Wythenshawe: 6-week Take Back Your Life Mindfulness course Monday 6th Feb to 13th March, 1pm - 3.30pm each week.
Healthy Me Healthy Communities / Gorton Community Centre: 6-week Take Back Your Life Mindfulness course, Tuesday 7th Feb to 14th March, 10am - 12.30pm each week.
No 93 Wellbeing Centre, Church Lane, Harpurhey: 6-week Take Back Your Life Mindfulness course, Tuesday 7th Feb to 14th March, 2pm - 4.30pm each week
Anything else you would like us to know about you?
*
Any other comments?
*
Reporting and demographic information
To help us ensure the service is accessible to everyone in the community.
How did you hear about the course?
*
Age
*
Ethnicity
*
Please Select
Asian / Asian British (including Chinese)
Black / African / Caribbean / Black British
Mixed / Multiple ethnic groups
White (including White British, Irish, Gypsy or Irish Traveller)
Other
Prefer not to say
Gender
*
Please Select
Female
Male
Non-binary/other
Prefer not to say
Do you have a disability?
*
Yes
No
Prefer not to say
Do you have a long-term physical health condition
*
Yes
No
Prefer not to say
Are you a carer?
*
Yes
No
Safeguarding contact info
Emergency Contact Name (e.g. next of kin)
*
Emergency Contact Number
*
-
Area Code
Phone Number
Name of GP Surgery
*
Please note that we will only contact your GP if you report any risk to yourself or others
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