Cape Town, South Africa
+27 (82) 921 5012
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.
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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.
Please say why you wish to do a mindfulness course.
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?
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.
If you have a counsellor, therapist or mental health worker it is a good idea to talk to them about this 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, I will arrange to discuss this with you. At this stage I may feel it would be helpful to contact your mental health support person. In my experience this is extremely rare, however, to best take care of participants on the course, this may be necessary. If you are willing for this to take place, please supply a name and telephone number here.
Name of mental health support person:
Alternatively, if you do not have a mental health support person, please provide a next of kin or friend or even your GP that I can contact regarding your wellbeing if necessary. 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.
Name of next of kin / friend / GP:
I give permission for Bianca to contact one of the above support people 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?
Please consider who can support and encourage you while you do the course.
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 checkboxes under Support and Recordings in order to give the necessary permissions.