Weekend Retreat Questionnaire

Your Name:

Email address:

Phone Number:

Occupation

Any dietary requirements?

Have you done MBSR before?

Have you done a silent retreat before, and if so detail your retreat experience?

What is your interest in this retreat?

Current daily or weekly meditation practice(s)

Any history of physical illness or current physical limitations that might be aggravated by, or interfere, with sitting and/or walking.

Are you currently seeing a therapist or counsellor?

Additional information or comments you would like the teacher to know so that we can best support you.

In the event of an emergency my closest contact is: Name / Relationship / Contact details:

Thanks for enrolling in this retreat. We hope it brings you more ease, clarity and wisdom. We look forward to seeing you there.

Caroline will be sending you an email about the logistical details for this retreat, including what to bring.

Please complete this questionnaire below.