Cape Town, South Africa

    MBSR COURSE QUESTIONNAIRE

    YOUR CONTACT DETAILS

    In terms of POPIA, do you give me permission to keep these contact details on record after the course is finished so that I can keep you informed of other Mindfulness Practice courses and events that I may run? Please note that I will never give this information to any other person or organisation.

    PERSONAL INFORMATION

    This information is to help me ensure that the course meets your needs at present. The information will not be shared with anyone else, will be kept securely online and deleted as soon as the course is completed. Please contact me if you wish to know more about my data protection policy.

    If you would prefer to talk to me about any of these questions rather than fill in the form, that can be arranged. Please email me to make a time to discuss these over the phone.

    YOUR EXPECTATIONS

    YOUR HEALTH

    1. Do you have any physical illness or other limitation that may make sitting, standing walking or doing simple exercise difficult for you?

    2. Do you have any difficulty with sight or hearing?

    3. Have you experienced any mental ill health, such as anxiety, depression or any distressing life event in the last six months, (e.g. bereavement, loss, redundancy)? If so, please provide brief details if you can or let me know if you would prefer to have a call to discuss.

    4. Are you taking any medication for your mental health at present? If so, please say what it is and what it is for.

    5. Have you experienced any traumatic event in your life (e.g. sexual abuse, assault) or do you suffer, or have you ever suffered, from PTSD or panic attacks? Please provide brief details if you can or let me know if you would prefer to have a call to discuss how this course might trigger traumatic events from your past.

    6. Is there anything else you think it would be helpful for me to be aware of?

    SUPPORT

    Undertaking a course of this type offers an opportunity for change and change can be challenging at times. I am there to support your learning; however, I encourage you to also have your own support system to help you get the most out of the course.

    Very occasionally difficulties encountered on this course can feel overwhelming which may give concern for your well-being and/or safety. If this happens, please remember that you have the BFM counselor that you can contact. At this stage, if I feel it would be helpful for you to make contact with the BFM counselor, I will discuss this with you. In my experience this is extremely rare, however, to best take care of participants on the course, this may be necessary.

    I give permission for Bianca to contact the Bridges For Music counselor if she is concerned about my wellbeing:

     

    Alternatively, if you have your own mental health support person, or a next of kin or friend that you would prefer me to contact in the event that I am concerned about your well-being, please provide their details below. It is a good idea to let this person know that you are doing this course and that I may contact them, if necessary, but again, in my experience, this is extremely rare.

    I give permission for Bianca to contact the above support person if she is concerned about my wellbeing:

     

    COURSE COMMITMENT

    A commitment to attending all classes is very important. Are there any dates you know in advance which you know you will be unable to attend? Please list them.

    Are you able to commit to practise at home?

    Please consider who can support and encourage you while you do the course.

    RECORDINGS

    For my development as an MBSR facilitator, I may need to record parts or all of the sessions. These will be a combination of audio and video recordings. The camera will always be focused solely on me, and I will position it as best I can so that no participant can be seen. Please note that these recordings are used solely to support my ongoing teacher development and competency assessment.

    I give permission for recording of the sessions on the understanding that the recordings will only be shared with Bianca's supervisor.
     
     

    If you are unable to click the Submit button, please check that you have ticked the checkbox under Recordings in order to give the necessary permission.

    Have a question?

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