Compassionate Mind Training Registration

Name *

First

Last

Email *

Phone number *

Please confirm that you have booked a place on the course for yourself and not for anyone else, and that you are completing this registration information on your own account. *

I confirm

(If you cannot confirm the above, please contact me to make alternative arrangements.)

What is your home address? *

(Please include your borough and postcode)

How old are you? *

Are you currently registered with a GP? *

Yes
No (not currently registered)

GP Practice Address (including borough) *

(If not you're not currently registered with a GP put "N/A")

What is the name of your GP? *

(If not you're not currently registered with a GP put "N/A")

Where did you hear about the Compassionate Mind Training course? *

Will you be able to attend all 8 sessions? *

Yes
No

(Occurring every Monday from January 25th to March 15th, 2021)

What do you hope to gain from this course? *

Do you have any concerns about taking this course in a group setting?

Please indicate if you have ever had a diagnosis, or experienced symptoms of, any of the following conditions: *

Are you currently experiencing stress, anxiety, depression or any physical or mental health difficulties? If this is the case, please provide details below and describe how these affect your life, or have in the past:

Are you currently taking any medication or receiving any other treatment for your mental health? *

If so, please specify the treatments/medications.

What other coping mechanisms do you currently use to manage your mental health and well being? *

Do you have any other specific needs that I should be aware of? *

Is there anything else you'd like to share?