Mindfulness Facilitator A application form

Mindfulness Facilitator A

Application Form
If you have any questions about completing this form, you can email us on info@breathworks.co.uk or call 0161 834 1110.

Please allow yourself up to 30 minutes to complete this application form. Click on each of the grey boxes and provide the information requested.

Our administration team will then process your application and be in touch about next steps within 2 weeks.

A few of the questions have a * by them - these need to be answered to submit the form. The other questions are not compulsory however, we would really appreciate you answering all the questions. All information is provided in complete confidence and helps us to:
- identify the appropriate level of training for you
- provide the best conditions for participants on our events
- helps our teachers/trainers to gain some idea of the participants.
Thank you,

The Breathworks Training Team
Booking Information
Choose your dates below:*
Please select the rate you will be paying:

IndividualOrganisationConcessionI am paying/have paid via the Stage 1 Bundle option
Which Bundle Price will you be paying?

Individual - all onlineIndividual - MFB in personConcession - all onlineConcession - MFB in personOrganisation - all onlineOrganisation - MFB in person
If an organisation is paying, please provide invoicing details:
Stage 1 Bundle means paying for all Stage 1 modules at once and receiving a discount of 10%. If you would like to request a payment plan, please let our training team know by email.
OpenCRM Event
BUNDLE OpenCRM Event
Please tell us some basic information
Please upload a head & shoulder photo of yourself so we can easily identify you when you come along to our training:
Cancelof
Name:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
E-mail 2
example@example.com
Mobile Phone*
Home/Work Phone
Date of Birth*

DayMonthYear
Gender*
What are your pronouns?
Ethnicity*
Please tell us about your practice
In order to participate in Mindfulness Facilitator A, we ask that you have completed one of Breathworks' 8 week courses and have had a mindfulness practice for a minimum of 2 months.
Courses Attended*

Breathworks Living Well with Pain and Illness / Mindfulness for Health 8-week courseBreathworks Mindfulness for Stress courseOther (e.g. Breathworks Workplace course or Residential Intensive Course)
Please Specify
Length of practice*
Please state the year you attended the course and the course provider (organisation/teachers name):*
Please provide contact details for the organisation/teacher who provided the course:
If you have provided contact details above, would you be happy for us to contact this person for a reference?

YesNoOther
We'd like to know about your experience and practice of mindfulness. Please share a bit about why you practice, what context you practice within (professional, religious, self-led, etc.), the types of practices you do, and what your daily practice looks like.
Why I practice mindfulness*
My regular types of practice and the context for my practice*
What my daily mindfulness practice usually consists of*
Please tell us a bit about your process of how you work with your own experience of pain, stress or illness or any other kind of suffering, both in meditation and in your daily life.*
Reasons for applying
Please tell us a bit more about your reasons for applying to the Training Programme. What do you hope to get out of participating and how does this apply to your personal and professional goals?
Reasons for applying*
How do you hope to make use of your training? Please select your top two reasons*

To enhance my personal practiceTo incorporate mindfulness into my work with patients or clientsTo lead Breathworks courses in my place of employmentTo lead Breathworks courses as an independent mindfulness teacherOther
Please tell us if you have trained to teach any of the following:

MBSRMBCTDBT (Dialectical Behavioral Therapy)ACT (Acceptance and Commitment Therapy)Other
Educational background*
Please tell us a bit about your educational background ie degrees, professional qualifications or other certificates earned.
Additional Training/ Experience*
Please tell us about any additional training or experiences you have had that you feel are pertinent to this application.
Profession*

Registered NurseGeneral PractitionerOccupational TherapistPhysiotherapistOther Healthcare professionalTherapistCounselorPsychologistOther Mental Health professionalHolistic Therapist (eg yoga teacher, massage therapist etc.)Mindfulness TeacherTeacher/LecturerResearcherOther Educational professionalOther
Work Experience*
Please tell us a bit about your work experience, ie the field you are in, jobs held, client-type etc.
Are you interested in continuing on to take our full Teacher Training?

YesNoUndecided
Health and Accessibility Information
Do you currently have any physical health conditions?*
If yes, how does this condition affect your ability to hear, see, sit, stand, walk or engage in mindful movement?
Have you had any mental health issues within the last few years (such as anxiety or depression)?*
If yes, have you ever, or are you currently receiving treatment?
Dietary requirements
If you have particular access or communication requirements which need to be met in order for you to engage fully with the Breathworks training programme (eg. related to dyslexia, physical or mental health conditions, sensory impairment, restricted mobility etc). Please give details:
Is there anything else you'd like to share with us?
Emergency Contact Details

Please provide contact details for who we should contact in case of an emergency when attending a programme with us.
Emergency Contact Name*
Emergency Contact Phone Number*

Area CodePhone Number
If there is an incident/accident/ flare up of your health condition during one of our events, is there anything we need to know to help get you the support you will need? eg list of medication, usual steps you take
Keeping in touch
How did you hear about Mindfulness Facilitator A*

Breathworks websiteVirtual Online Open DayInternet search (Google or other)Friend or relativeIn the workplace/by a colleagueMedical professional e.g. doctor, pain clinic, counsellorSocial mediaBreathworks Community of PracticeBreathworks emails & newsletterCommunity or spiritual groupOther
Please Specify
Communication Preferences

We'd love to add you to our mailing list so you can enjoy our monthly mindfulness newsletter and be the first to know about events & promotions we think you'll love. We'll keep you present, not pestered. If you're happy to hear from us, please tick the box below.
I would like to join the Breathworks mailing list
Newsletter
Activity subject
Date of submission

MonthDayYear
Contact Type
Activity status
Should be Empty:

Mindfulness Facilitator A

Booking Information

Please tell us some basic information

Please tell us about your practice

Reasons for applying

Health and Accessibility Information

Emergency Contact Details

Keeping in touch