Going Deeper Booking Form

Going Deeper

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

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:
- ensure this course is appropriate 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
OpenCRM Event
Choose your dates below:*
Please select the rate you will be paying*

IndividualOrganisationConcessionI would like to pay for Stage 1 BundleI have paid for Stage 1 Bundle
If an organisation is paying, please provide invoicing details:
To pay the Stage 1 Bundle, you must fill in the more detailed application form for Mindfulness Facilitator A so we can assess whether you have fulfilled all the prerequisites for Stage 1. You can access the form here.
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 when they confirm your place.
Please tell us some information
Name:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
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 Going Deeper, we ask that you have completed one of our 8 week courses or have an established mindfulness practice.
Courses Attended*

Breathworks Living Well with Pain and Illness / Mindfulness for Health 8-week courseBreathworks Mindfulness for Stress courseAn 8-week MBSR/MBCT courseI have an established Mindfulness practice
Length of practice*
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 do you practice mindfulness and what does your practice involve?*
Please tell us a bit about what you hope to get out of your experience on the 'Going Deeper' course*
Will you be continuing on to take the full Breathworks 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?
If you have particular access or communication requirements which need to be met in order for you to engage fully with 'Going Deeper' (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 Going Deeper*

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
Training Programme Application Form
If you have any questions relating to this form, email info@breathworks.co.uk or
Should be Empty:

Going Deeper

Booking Information

Please tell us some information

Please tell us about your practice

Health and Accessibility Information

Emergency Contact Details

Keeping in touch