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8-Week Mindfulness Course: Patients
Wednesdays @ 6pm

If you would like to enroll on this course, please complete the information below.  The answers you provide will be treated as confidential and will only be used for statistical and research purposes and enables our mindfulness tutor to help you as best as she can.

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* 1. What is your full name?

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* 2. What is your email address?

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* 3. What is your current address?  (Please include House No, Street, Town, Postcode so that we can post out your welcome pack)

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* 4. what is your phone number?

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* 5. What is your age?

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* 6. Gender?

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* 7. Type of cancer

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* 8. Stage of cancer

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* 9. Stage of treatment

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* 10. How did you find out about Friends of ANCHOR's mindfulness course?

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* 11. This mindfulness course is educational and not intended to be a treatment for mental health problems.  If you have recently received or are currently receiving treatment from a psychiatrist, psychotherapist or counsellor for an ongoing mental health problem, we strongly advise that you obtain approval from your mental health professional before proceeding further.   Also if you have recently or are currently going through a traumatic life event or are experiencing extreme emotional distress, then please consider carefully whether starting a course now is the right time for you.  This will very much depend on your current psychological health and the support networks you have around you, such as friends, family, and mental health professionals.  For anyone withdrawing from the course for these reasons the option is available to you to take up the course in the future.

If you are currently taking medication for a mental health problem, then we recommend that you do not change your medication, unless in close collaboration with your medication prescriber.

The decision to perform any of the exercises and meditations in this course remains your own, so please follow your own careful judgement to decide if they are beneficial for you for you to do or not. 

If any of these circumstances apply to you, then if you have not done so already, please contact your teacher - Louise Martin, before the course begins to discuss your situation and how you can best be supported during the course.

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* 12. Signature (type in your full name)

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