Cape Town, South Africa

Thank you for your interest in attending the upcoming MBSR course. Please complete the form below. If you have any questions or concerns about filling in this form, do not hesitate to contact me. Thanks Bianca.


    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.


    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 contact me to make a time to discuss these over the phone.



    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? A course like this can sometimes trigger traumatic events from your past. It is important that you are well taken care of and have access to psychological support, if needed. This is especially important if you have never discussed the traumatic event with anyone. If you are able to, please give brief details below of the traumatic event and whether you had the support of a counsellor.

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


    Very occasionally difficulties encountered on this course can feel overwhelming which may give concern for your well-being and/or safety. If this happens, I will arrange to discuss this with you, but I am not a clinically trained counsellor. It is therefore important for you to identify a support person that I can contact if I am worried about you. This person can be a therapist, your doctor, a next-of-kin or friend. Someone that you are happy for me to contact about your wellbeing. 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 above support person if she is concerned about my wellbeing.


    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?

    Sometimes it becomes difficult to do the home practice and you may lose motivation to complete the course. Please consider who might be able to support and encourage you while you do the course.


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

    Have a question?

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