Mindful Self-Compassion form

8 -week 9 session programme (all formats including 5-weekend programme and online short course )
Background Information is strictly confidential

Title
  • Mr.
  • Mis.
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First Name
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Last Name
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Address
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E-mail Address
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Would you like to be included on a regular mailing list /receive my newsletter to receive information about future courses and events?
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Home Number
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Mobile Number
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Gender
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Type Gender Here
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Partnership Status
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Type Partnership Status Here
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Occupation
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Why are you interested in participating in this program?
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Do you have a regular practice of meditation? If so, what type and how many years have you been practicing?
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How would you describe your physical health:
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Are you currently in psychotherapy?
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Are you currently taking psychoactive medication, or any medication that may affect how you feel from one week to the next?
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Please provide details
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