Pre-course Form for the 8-Week Mindfulness Course (MBCT/MBSR)
To help me teach the MBCT/MBSR course, please can you complete the following standard
questionnaire. You needn’t fill it out in great detail and some questions are likely to not be
relevant to you.
This form might give the impression that the course is mainly for people with more serious
emotional or psychological difficulties. That is definitely not the case – the course is
relevant for everyone: including those who simply want to learn to be awake to the present
moment; those who want to manage work stress better; while also being relevant for people who
are facing more serious life challenges. This form is partly to help me assess though that it
really is the right time in your life for you to do the course, and also to get a sense of
anything I might need to take into account when I’m teaching the course.
Please return by
email to nick@mindfulnessforwellbeing.co.uk (<- you can press cntrl and click on
this link and then add your completed form as an attachment). Or you can print it
and send it to: Nick Diggins, 15 Ladysmith Rd, Brighton, BN2 4EJ.
This information will be kept confidential and destroyed after the course.
Name
Email
Telephone (preferably mobile)
Address_________________________________________________________
Which course (i.e.day & time)?……………………………
1.
Please indicate briefly here what you are hoping to get out of the course.
2. Have you had any major stressful life event in the last year (or currently ongoing) which
affect your experience on the course (such as trauma, bereavement, work/home-life stress)?
3.
Can you please confirm that you have read the ‘info’ page on my website? Yes / No.
4. Do you have any physical illness (including allergies) or other limitation that may make
sitting, standing, walking or doing simple exercise is difficult for you (you can still do the
course if you do)?
5. Could you please say briefly whether you feel comfortable speaking in groups or if you find
that difficult? (There’s no requirement to speak in the class but I do my utmost to make the
space feel safe for anyone to share their experience of doing the meditations in the group if
they want to).
6. Have you seen a mental health professional recently or in the past? If you answer ‘yes’, it
would be very helpful for me to know when and also whether you were given a diagnosis (although
I know that diagnoses sometimes aren’t that accurate).
7. If you are taking any medication at present to support your mental health, please say what
it is and what it is for.
8. Please indicate what sources of support you will have during the course, eg. friends,
partner, family, GP, counsellor, support worker.
9. Have you had suicidal thoughts or feelings during the last year, and if not have you ever
had suicidal thoughts or feelings?
10. Please also give details of your GP (name and surgery). If you have a support worker/ carecoordinator regarding your mental health or there are any other mental health professionals
that you are in contact with please also give their details (or please discuss this with me if
you feel this isn’t appropriate).
11. Are you able to come to one of my Free Talks (see the front page of my website for dates) and if so which
one? If you’re not able to come to a talk and we haven’t spoken at least briefly already, can you suggest a time
when we could have a short chat on the phone?
12. Where did you hear about the course? If ‘online’ it would help me if you could remember which website.
Thank you for taking the time to complete this questionnaire. The information may be shared (anonymously)
with supervisors, to help me run the course as effectively as I can. If I have serious concerns about your
wellbeing or the wellbeing of someone else on the course then I might have to break your confidentiality,
though I would discuss this with you first – and for the record, this has never actually happened in all the courses
I’ve taught (nor for that matter in any of the courses taught by any of my colleagues).
Signed (name) …………………………………….
Date ……………………………………….