Application Form

Foundations of Mindfulness: A Five-day Retreat

Foundations of Mindfulness: A Five-day Retreat – 20/07/2020 – 24/07/2020

Terms & Conditions

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I confirm by ticking this box that I have read the course description and relevant information sheets and understand and agree to the payment and cancellation arrangements of the Mindfulness Network.
About you
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Emergency contact:
Telephone number:
Relationship to participant:
Where did you find out about this course?

Please state:

Your physical health
Please provide the name of your GP:
Please provide the address of your GP:

Please provide the phone number of your GP:
Do you have any current medical conditions?
Please provide further details of your current medical conditions:
Do you have any physical illness or other limitation that may make hearing, sitting, standing, walking or doing simple exercises difficult for you?

Please provide further information about your physical illness/limitation:
If you have significant physical health problems, please tell your GP that you are undertaking the course.

Your mental health
Have you had any mental health issues or concerns within the last few years, such as anxiety or depression?

Please provide further information regarding mental health issues or concerns:

Are you taking any medications or over-the-counter drugs at the moment?

Please list your medications here:

Have you ever received psychiatric or psychological treatment before?

Please provide further information regarding psychiatric or psychological treatment received:

Have you ever made a suicide attempt?

Please provide further information:

If you are currently receiving counselling, psychotherapy or any mental health treatment please tell your therapist that you are undertaking the course.

Alcohol and other substance abuse
Has alcohol or drug use (including over-use of prescribed medication) ever caused problems for you?

Please provide further information:

Experiences of upsetting events
Sometimes things happen to people that are extremely upsetting – things like being in a life threatening situation like a major disaster, very serious accident or fire; being physically assaulted or raped; seeing another person killed, dead, or badly hurt, or hearing about something horrible that has happened to someone you are close to. At any time during your life, have any of these kinds of things happened to you?

Please provide further information:

Sometimes these things keep coming back in nightmares, flashbacks, thoughts that you can’t get rid of. Does this happen to you?

Please provide further details:

Do you ever get upset when you are in a situation that reminds you of one of these terrible things?

Please provide further details:

Course fees
You can choose to pay the entire amount for this event or just the deposit. However, if your application is within 4 months, then you will be invoiced for the full amount. If you have paid a deposit, 4 months before the start date you will be invoiced for the balance which must be paid within 30 days. If the total cost of the event is less than £500 the deposit will not be listed as an option.

Please select the fee that you’re paying.

Is your fee to be paid by your employer?

Employer name:

Employer’s address:

Employer’s postcode:

Contact name at employer:

Contact e-mail address at employer:

Contact phone number at employer:

Do you have a purchase order number – if you are working within the NHS, this is usually necessary:

Mindfulness Practice
Please advise about your duration of personal practice – e.g. under 1 year, 1-2 yrs, 3-5 yrs, 6-10 yrs, over 10 years

Please detail of the style/tradition of practice – e.g. MBSR/MBCT approach, Buddhist tradition (say which), other (give details)

Details of Mindfulness training:
Participation in 8-week course(s) and date(s)

Participation in further ‘deepening’ courses (give details)

Teacher training (give details)

Are you currently teaching MB courses? If so please give details

Retreat experience
How many previous retreats have you attended, please also detail when, where and approx duration.

All meals will be vegetarian, but please let us know if you have any special dietary requirements

Please give details of any previous mindfulness courses, and/or training you have attended.

Please indicate briefly what you hope to get from this event.

Any other information you would like to pass onto the admin team or teachers in connection with this application: