Select the course you wish to attend : 8 Week Mind Body Balance Class - Hoylake 8 Week Mindfulness Based Programme - Liverpool 5 Day Mindfulness Teacher Training Programme Cultivating Emotional Balance Programme (CEB) Cultivating the ‘Good Life’ 8 Week Mindfulness & Compassion Based Programme *

First Name : *

Surname : *

Address : *

Postcode : *

Telephone :

Email : *

Please answer the following questions :

1. Do you have any physical illness or other limitations that make sitting, standing, walking or doing simple exercises difficult for you? Yes No

If so please tell us about it here:

2. Are you pregnant? Yes No

3 Have you had any mental ill-health within the last few years, such as anxiety or depression? Yes No

If so please tell us about it here:

4. Have you experienced any major life event within the last few years? Yes No

If so please tell us about it here:

5. Are you on any medication at present, please say what it is and what it is for: Yes No

Doing this kind of work can at times be challenging, for some people. The teacher will be there to support you throughout the course. However, we also very much encourage you to have your own additional support network during this time.

For some people undertaking this work may feel a little overwhelming at times, giving rise to concern about their wellbeing and/or safety. In this event the teacher will discuss any concerns with the participant. If this does not adequately help to resolve concerns and the teacher remains concerned for the person’s immediate health and/or safety, the teacher will then need to contact the participant’s GP. In our experience this situation is rare.

Please supply GP details:

I am fully aware that engaging in this work can at times be emotionally challenging. However, it is my decision to take part in this programme and accept full responsibility for my own health and wellbeing. Yes No

I Have Read the Terms and Conditions *

Thank You for your booking