Cape Town, South Africa

    MINDFULNESS STUDY 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 until after the research study is finished so that I can contact your for the duration of the study? Please note that I will never give this information to any other person or organisation.

    The mindfulness course for this research study will be conducted in English. Please indicate below whether you are able and willing to participate in the mindfulness training in English.

    PERSONAL INFORMATION

    The below information is to help me find out a bit more about you for the research study 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 other than my supervisors, will be kept securely online and deleted as soon as the research study 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 or whatsapp me to make a time to discuss these over the phone.

    PERSONAL DETAILS

    1.Are you over 18 years old?

    Age (optional):

    YOUR MARRIAGE STATUS

    1. Are you married?

    2. When did you get married?

    3. Were you married according to traditional Xhosa customs, including renaming (ukuthiywa)?

    4. What is your given birth name*:

    5. What is your new name given to you by your husband's family*:

    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 3 - 5 participants. Is there anything that might affect your participation in the 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.

    In addition to the weekly sessions, practicing mindfulness at home is encouraged in between the sessions. Please consider who might be able to support and encourage you while you do the course.

    PARTICIPATION

    1. Please note that participation is voluntary.
    2. You may withdraw from the study at any time without penalty.

    THE NEXT STEP

    The answers you submit for this questionnaire will be reviewed, possibly in conjunction with my supervisors, to consider whether now is an appropriate time for you to be doing a course like this. A response will be sent to you by email and if everything is okay, you will be invited to an on-site Information Session.

    If you have any questions please feel free to contact me:
    Bianca Browne
    0829215012
    bianca@mindfulnesspractice.co.za
     
     

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