Pre-Questionnaire "*" indicates required fields Name* First Surname Email* Phone NumberAddress* Street Address City State Post Code OccupationAgeHow did you find the course? Please select:* Practice for Mindful Living newsletter Google search Medical referral Therapist Friend Family Colleague/Supervisor Openground Practice for Mindful Living website Other The other way I found out about the course wasWhat current challenges have brought you to the MSBR course?What has helped?What challenges might come up in finding time for the home practice each day?Have you experienced things in your life that were overwhelming, either earlier on in life, or more recently?Do you have any medical conditions that might affect your participation in the program? For example, any physical or mental illnesses?Do you have a current Mental Health Care Plan from your GP to seek psychologically focussed treatment?*If so, you could be eligible for a rebate for each class you attend. Refer to the payment information within your confirmation letter. I will require a copy of this referral to have all the information I will need to prepare the receipt at the completion of the course. Yes No Are you currently seeing a counsellor or therapist? If so, will you have access to their support if any concerns arise within the course of your participation?What strengths do you bring into learning something new like this?Have you completed your payment for the course?*All the information about the fees are provided within your confirmation letter. Yes No I give my informed consent to participate in the course*I have been informed of the risks and benefits of doing the MBSR outlined in the article What to expect in doing a Mindfulness Based Stress Reduction course, which has been made available in the confirmation email. Yes
