Mindful Psychology

Marijke Batenburg

MA (Hons), Dip Clin Psych, Dip Al Counselling, FNZCCP

Living Mindfully (MBCT) Registration Form

Living the Mindful Way - Winter series
July 2012

Start date: Tuesday 10th July
Times: 6.15pm - 8.45pm
Retreat Day:Sunday 12th August
Location: Mercy Hospice College Hill, Ponsonby

CONFIDENTIAL Application Form

Surname
First Name
Address
Telephone: Home
Telephone: Work
Telephone: Mobile
Email address
Date of Birth
Occupation
Please list any medications you take
Your usual GP
GP practice address
May I leave messages (discreetly) for you at work?
May I leave messages (discreetly) for you at home?
May I leave messages (discreetly) on your mobile?
How did you learn about this course?
What draws you to this course?
What is your experience with mindfulness or meditation practice?
What are your doubts and hopes about your participation?
What is the cross road you are at which draws you to this programme now?
At times follow up, 3 months after the course, is appropriate. Do you agree to receiving a follow up call or email from the facilitators?

Thank you for taking the time to fill out this form.

Privacy Act: The information requested on this form will only be used by the facilitator of Living Mindfully -Marijke Batenburg Registered Clinical Psychologist for the provision of Mindfulness Based Cognitive Therapy programme (MBCT).

Mindful Psychology

Marijke Batenburg

MA (Hons), Dip Clin Psych, Dip Al Counselling, FNZCCP

mindfulness

Living Mindfully (MBCT) Registration Form

Living the Mindful Way - Winter series July 2012

CONFIDENTIAL Application Form

Living the Mindful Way - Winter series
July 2012