Cape Town, South Africa

    MBSR COURSE QUESTIONNAIRE

    YOUR CONTACT DETAILS

    Do you give me permission to add your number to a whatsapp group for the purposes of the mindfulness course?

    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 find out a bit more about you and also to ensure that now is a good time for you to be doing a course like this. 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 contact me to make a time.

    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. Are you currently seeing a psychologist or counsellor? If so, it is necessary for you to speak to them about doing this course and get a consent form from them to indicate that now is a good time for you to be doing a course like this.

    4. Have you experienced any mental health illness such as anxiety, depression or suicidal thoughts? If so, can you provide brief details as well as the details of any medication you may be taking or have taken for this.

    5. Have you experienced a difficult life event in the last 6 months such as bereavement, divorce, job loss or any other major change? If so, can you provide brief details.

    6. Do you suffer, or have you ever suffered, from Post Traumatic Stress Disorder (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.

    7. Have you previously struggled with substance abuse (e.g. drugs or alcohol)? If so, please indicate for how long you have been in recovery.

    8. Our group will be a small group of about 8 participants. Is there anything that might affect your participation in a group setting that you would like to let me know about?

    9. Have you ever experienced intwaso (healing sickness) or felt that you might be receiving an ancestral calling to heal?

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

    SUPPORT

    Very occasionally difficulties encountered on this course can feel overwhelming which may give concern for your well-being and/or safety. If this happens, you will be referred to the Bridges for Music counsellor for support. The researcher/ facilitator is not clinically trained. Please give your permission below OR give the name and contact details of your own mental health support person in the textbox below.

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


     

    COURSE COMMITMENT

    A commitment to attending all 8 classes and the retreat morning is important. What things might prevent you from attending all the sessions and finishing the course? Please list them.

    Unfortunately if you miss 3 or more of the classes, you will be asked to rather attend the course at another time when you are better able to commit to attending more sessions.

    In addition to the weekly sessions, practicing mindfulness at home is encouraged in between the sessions. The recommendation is 30-45min per day. Please consider who might be able to support and encourage you to while you do the course.
     
     

    Have a question?

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