Mindfulness Courses Application Form 2019-03-22T20:53:00+00:00

Mindfulness Course Application Form

Please complete the application form below as fully and accurately as possible. Once completed please submit the form and make your payment by bank transfer to confirm your place.

If you prefer to pay by cheque or cash or want to return your form by post or email, the course application form and payment details can be downloaded from the “Downloads‘ section of ‘Resources’.

All information is used for assessment of course suitability only. Any information given is strictly confidential and will be seen only be myself, Wendy Broad and if necessary discussed with my supervisor. I operate according to the terms of the UK Mindfulness Teachers Good Practice Guidelines, requiring ongoing supervision.

Your information will be kept according to data protection legislation and will be destroyed after 5 years as a condition of my insurance.

Please Note:

These courses/ sessions involve noticing the sensations of your breath and the physical sensations and feelings in your body, as well as observing thoughts and emotions. If you have a sense that this may be very difficult for you, it may be better to wait before starting the course. If you would like to talk to Wendy before making your application, please feel free to contact her and she will call you back.








Emergency contact number:

GP's name & address:

Where did you find out about this course?


1) What has brought you to choose this particular course? Please outline briefly.

2) Please give details of any previous mindfulness courses, training or retreats you have attended.

3) For group courses, you will be asked to talk in pairs from time to time, but do not need to contribute to larger group discussions if you do not wish to. Groups vary from 8-14 participants. Are you comfortable working alongside others in a group situation? YesNo

4) Please could you give details of any stressful life events you have experienced in the last few years which could make the course difficult for you, such as physical or emotional trauma, bereavement, job loss, divorce or separation. If you have not experienced stressful life events please write None.

5) Have you experienced any health problems in recent years e.g. anxiety, depression or other mental health conditions? YesNo

6) For these mindfulness courses you are invited to spend 10-20 minutes per day on home practice. Is this something that you are willing to do? YesNo

7) Do you have any particular needs that it would be useful for us to know about e.g. restricted mobility, hearing or visual impairment? If there are none, please respond with None.

8) Are there any questions or other information you would like to pass on to the teacher in connection with this application?

Mindfulness Course Agreement

I understand that this is an experiential course/ session and is not group therapy or group counselling.

I agree to take care of myself as best as I can during the course/ session and observe the guidelines and instructions throughout.

I understand that I will be noticing my thoughts, emotions, feelings and bodily sensations, including becoming aware of my breath.

I agree to inform the teacher by text, phone or email if I cannot attend.

I understand that all course fees must be pre-paid in advance at the time of making the booking and if the teacher decides that the course is not suitable for me prior to commencement of the course, my full payment will be refunded promptly.

Cancellation Policy

If a cancellation is made within 5 weeks of a course start date, a refund is not possible. Course fees may be refunded less a £25 administration fee if more than 5 weeks cancellation notice is given. Once the course has started, refunds are not possible. The payment will be refunded if the course is cancelled.

Data Protection Policy and Privacy Policy

I have read and agree to the Data Protection Policy and Privacy Policy.

Participant's Signature: (a computer-generated signature is fine)


Please feel free to contact me if you need more information.

Many thanks,
Kind regards,

Course Payment:

Please make your payment at the time of sending your booking form.

Cost: Non-residents £95, Willowmere residents £60.

On-line bank payments

If possible, please could you return your form on-line and make your payment by direct on-line bank transfer, thanks. My bank details are:

Sort code: 11-05-70 (Halifax)
Account: 00091218
Reference: your name

Cheque payments

Please send cheques at least 2 weeks prior to the course start date, thanks.

If you prefer to send a cheque, please make it out to Wendy Broad and forward with your booking form to 15 The West Wing, Bostock Hall, Middlewich, Cheshire, CW10 9JN. Please write your address on the back of the cheque, as well as the course title, thanks.

Cash payments

Please contact Wendy to arrange payment by cash, thanks. M: 07795 243346