Booking/Registration Form
Taking Mindfulness Deeper 2014
Dates……………………….
Title
First Name
Surname
Address
Phone No (day and evening)
E-mail
Where did you hear about this course?
Occupation:
Please detail any particular mobility or other requirements that you would like us to know about.
Signature
Date
Please contact the office in the first instance to check availability. We accept payment by cheque
or by debit card/credit card. Please make cheques payable to ‘Sharpham Trust’ or call 01803
732542 between 9.00am and 1.00pm Mon – Fri to make a card payment.
Please return this form to:
Bookings Secretary, The Sharpham Trust, Sharpham House, Ashprington, Totnes. TQ9 7UT
Email: bookings@sharphamtrust.org
Tel: 01803 732542
Cancellation arrangements:
Bookings cancelled up to 21 days from the course start date are eligible for a full refund or,
alternatively, you can transfer to another course of the same value.
Bookings cancelled less than 21 days from the course start date are not eligible for a refund,
however, in certain circumstances, and at the Trust’s discretion, your place can be transferred to
another course of the same value.
If we have a waiting list and can resell your place then we will repay you the full fee minus an
admin charge of £15.
If we cancel the course because there are not enough enrolments to make it viable, we will refund
you in full.
Please ensure that you complete and return the attached questionnaire well in advance of the
start of the course.
Confidential questionnaire
5 Week course in Taking Mindfulness Deeper
To help your course teacher, please answer the following questions. The information you give us is
strictly confidential and will be seen only by the teacher or their supervisor. The information is kept
securely during the course and destroyed after the 4-week course. The course teacher may contact
you before the first session if any information needs clarification.
Name: ……………..……………………. Date of birth: ……………
1. Please indicate briefly, what has drawn you to the course? (continue overleaf if necessary)
2. Please let us know where and when you did your 8-week course.
3. Do you have any physical illness or other limitation that may make hearing, sitting, standing,
walking, or doing simple exercises difficult for you?
If yes please tell us about it here:
4. Have you had any mental ill-health within the last few years, such as anxiety or depression?
If yes please tell us about it here:
5. If you are currently receiving Counselling, Psychotherapy or any Mental Health Treatment please
tell your therapist that you are undertaking the course.
Please give name of therapist :
And their telephone number:
6. If you are taking any medication at present, please say what it is and what it is for:
7. Have you had any disturbing life event in the last year, which may make the course difficult for
you?