Online Course: 06-06-2025 - Mindful Parenting

As part of our booking process, we kindly ask you to complete an application form. This helps us gather important background information to ensure that the course is the right fit for you at this stage in your life. Rest assured, all information you provide will remain confidential and is handled in accordance with our GDPR policy.

If you have any questions or concerns about the form, please don’t hesitate to reach out to us directly via email or include your questions within the application form itself. We are here to assist you!

First Name*

Last Name*

Preferred Name

Email*

Contact Number*

Date of Birth*

Town/City*

Postcode*

Emergency contact details:
(please provide details of someone that can be contacted in the event of an emergency)

Emergency Contact Name*

Emergency Contact Number*

How did you hear about this course? Eg. Word of mouth, social media, leaflet, other

Briefly, what do you hope to get from attending this course?

Please answer the following health related questions.
One of our facilitators will be happy to speak with you if you have any questions, please email info@mindful-parenting.co.uk. We may arrange a telephone call to discuss your application

Are you currently experiencing any thoughts that you would be better off dead or of hurting yourself in some way?*

Yes

Have you experienced psychotic episode(s) in the past?*

Yes

Do you have a diagnosis of Bi-Polar Affective Disorder?*

Yes

Are you currently receiving any psychiatric or psychological treatments?*

Yes

Are you currently receiving any talking therapy?*

Yes

Have you ever been hospitalised for mental health problems?*

Yes

Have you deliberately harmed yourself in the past year?*

Yes

Have you ever attempted to take your own life?*

Yes

Have you ever experienced a traumatic event which is currently affecting you?*

Yes

Have you experienced bereavement in the past year?*

Yes

Are your currently using alcohol or drugs to manage your stress/distress?*

Yes

Are there any current life changes (loss of home, job, relationship breakdown, too many work commitments etc.) that may be placing you under additional stress?*

Yes

Are there any other medical issues we should be made aware of?*

Yes

If you have answered Yes to any of the above, please provide brief details:

Click here to view our Privacy Policy. It explains how we will use and protect any information about you that you give us.

Please tick here to consent to your information being used as described in our privacy policy.

In signing up you agree to our Cancellations Policy – click this link to review. If you decide to change your mind before the course begins you are liable to pay the full fee unless someone else fills your place.

Please tick here to agree to our Cancellations Policy