MBSR Registration Form

The Mindfulness Based Stress Reduction training is a structured educational training in mindfulness. In order to ensure this course is right for you at this time, please complete the following registration form. We will contact you directly on receiving the form to confirm your place – you are then welcome to complete the booking by paying online.

Name*

Date of Birth

Phone Number*

Email Address*

How did you hear about the course?

List three things you hope to learn or gain from doing this course:

How would you rate your current stress levels from 0-10?
(0) = no current stress, (10) = high level of stress

Have you had any previous experience of mindfulness meditation?

Do you have any current medical conditions or special needs? Please specify.

Are you currently attending a mental healthcare professional, counsellor or therapist? Please specify.

Please list any medications you are taking:

Do you have the facility to listen to an mp3 recording e.g. iPhone / laptop?

Will you be attending the pre-course orientation evening?

Any questions?

By using this form you agree with the storage and handling of your data by beomindfulhealth.ie.