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Mindfulness Course February 2020 Application Form

Tuesday 11 February – 31 March 2020

Pre-Assessment Form – Confidential

You are warmly invited to complete this form as the next step towards being selected to attend our next mindfulness course.  We hope that it will offer you an opportunity to reflect on your interest in the course, gain a little more information, and let us get to know your current circumstances better.

Introduction

Mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and non-judgementally” (Jon Kabat-Zinn, Full Catastrophe Living 1994).

This eight-week course provides an introduction to mindfulness primarily through experiential learning, which includes discussion and working in pairs and small groups.  The learning is cumulative so it is important that you are able to attend regularly (at least 6 out of the 8 sessions including the first one), barring unforeseen events.  You will be learning new skills and habits, so an important part of the process will also involve setting aside up to 1 hour of home practice each day between weekly sessions.  The course is running each Tuesday afternoon between the dates above, and includes a half-day session on Saturday 21st March, which is mandatory.

You will need to be confident about being able to make the journey to Pauls Cancer Support Centre where the course is being run.  Please let us know if you have any mobility or other issues.  We would add that, in our experience, travelling long distances to get to and from the course can undermine some of its effect.  Therefore if you are likely to have to travel longer than an hour, you may wish to think of accessing a course nearer to you.

Finally, it is important to recognise that this is not a therapy group.  On occasion strong feelings can rise out of the work, so please consider where you might look to for emotional support should you need it.

If you are comfortable with the course as we have described it so far, please continue and complete this form.

Mindfulness Application February 2020

  • Please give the month/year. (e.g. other mindfulness courses, meditation, yoga, tai chi)
  • Diagnosis

  • Most recent treatments you have been receiving

    Please enter the expected date of completion for each below

  • Physical Issues

    This section helps us to accommodate your needs

  • Mental health/emotional issues

    Dealing with cancer can be one of the greatest challenges for any of us to face, and entails an emotional journey as well as a physical one. For people with a history of mental ill health this can be even greater. Therefore, in this section we ask about both your past and current emotional well-being.

  • (e.g. 6 months of psychotherapy during relationship difficulties in 2007, 8 weeks of counselling regarding cancer diagnosis in 2015): It is particularly important to let us know if you are currently having counselling or therapy or may be doing it during the course
  • (Partner, trusted friend, counsellor, GP etc)
  • Engagement with the course

    The following are factors that can affect your engagement with the course