Retreat Questionnaire » Mindfulness Training Institute

First Name

Last Name

Date of Birth

Occupation

Can you tell us if you have done some basic structured mindfulness training with a teacher before, for example - MBSR, MBCT or MiCBT or another mindfulness course. Please let us know: which course, with whom and when?

Have you done a silent retreat before, and if so detail your retreat experience?

What is your interest in this retreat?

Current daily or weekly meditation practice(s)

Any history of physical illness or current physical limitations that might be aggravated by, or interfere, with sitting and/or walking.

Are you currently seeing a therapist or counsellor?

If yes, is your therapist aware you are coming to this retreat?

Please list physical or psychological conditions you are currently taking medications for (condition and medication)

What are current stressors you face?

Are there experiences you have had in the past still causing you stress?

Do you have a history of trauma, and if so , are you actively experiencing symptoms that feel connected to this? Examples include flashback, nightmares, and difficulty with attention?

Have you ever been hospitalised for a psychological condition? if so, please describe with dates, diagnosis and treatment.

Have you ever attempted to take your life?

Are there present conditions or circumstances in your life which might be placing you under additional stress, or which might make meditation difficult for you at this time (e.g. fasting, substance abuse withdrawal, loss of loved one, job, etc.?)

Additional information or comments you would like the teacher to know so that we can best support you.

In the event of an emergency my closest contact is: Name / Relationship / Contact details:

I have read the Caution and Disclaimer and Indemnity clauses below.

Yes

Thanks for enrolling in this retreat. We hope it brings you more ease, clarity and wisdom. We look forward to seeing you there.

Caroline will be sending you an email about the logistical details for this retreat, including what to bring.

Please complete this questionnaire below.