Mindful Psychology

Marijke Batenburg

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

The Mindful Way – Mindfulness Based Stress Reduction (MBSR) Registration Form

The Mindful Way

Summer Series 2012
Wednesday evenings 6.15pm to 8.30pm
From 15th February - April 4th 2012, Retreat Day 24th March
Weekly sessions: Mercy Hospice meeting room, 61 College Hill, Ponsonby
Retreat Day: 24th March, 104 The Drive, Epsom

CONFIDENTIAL Application Form

Surname
First Name
Address
Telephone: Home
Telephone: Work
Telephone: Mobile
Email address
Date of Birth
Age
Occupation
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 attracts you to this programme?
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 facilitators of The Mindful Way -Marijke Batenburg and Lisa Markwick Registered Clinical Psychologists for the provision of Mindfulness Based Stress Reduction programme.

Mindful Psychology

Marijke Batenburg

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

mindfulness

The Mindful Way – Mindfulness Based Stress Reduction (MBSR) Registration Form

The Mindful Way

CONFIDENTIAL Application Form