Course Application

Fields with an * are required

Thank you for your interest in attending a Mindfulness Program. Before we can book you in, an application form needs to be completed so we can ensure you are getting the right course for your current needs. To apply, please fill in the form below and we will be in contact with you. If you would prefer to chat, please call us on 0488 064 228.

Please note: these funded courses are available for Tasmanian adults (over 18) and are not suitable for those seeking professional development.

MINDFULNESS PROGRAMS AUSTRALASIA (MPA)

Consent Form - the legal bit to do before you give your personal information!

As part of providing this service to you, our MPA Facilitators will need to collect and record personal information from you that is relevant to your current situation, such as your name, contact information, some medical history and other relevant information. This collection of personal information enables MPA to offer these services to you, capture overall regional service provision and plan future service improvements. The information is kept securely. In the interests of your privacy, it is used only by your group facilitator and the authorised staff at MPA. A more detailed description is available in our “Privacy policy for management of personal information”, which can be downloaded here.

By checking the box below you acknowledge that you have read and understood this Consent Form and agree to the above conditions for Mindfulness Programs Australasia to record your information and use this for your health, safety, data collection and reporting, directly related to the MPA service.

I, (your name in Block Capitals)

First Name *

agree to the above conditions *

Please note: If, after reading this form you are at all unclear about any of the information provided, please discuss these with your course facilitator, the MPA administration on 0488 064 228 or email your concerns to admin@mindfulnessaus.com.au. For any complaints please contact either Miranda on 0488 997 095 or Christine on 0427 824 759, and/or Primary Health Tasmania on 1300 653 169. You may also ask your facilitator for a Complaints/ Compliments form, or you may fill in the form online. We greatly appreciate your assistance.

The following questions should take about 5 minutes to complete – thank you!

Contact Details

Year of Birth *

Phone Number *

Email Address *

Post Code *

Do you experience any of the following? (Please select any that apply) *

StressAnxietyDepressionOther

Which course would you like to apply for? *

Were you referred to these courses? *

Please let us know how you heard about this program *

The following questions help us to understand how you have been feeling over the past 4 weeks.

Would you like to answer the questions that are more suitable for First Australians or Torres Strait Islanders? *

YesNo

If you answer Yes you will only be shown questions 2, 4, 5, 8 and 9.

1. In the last four weeks, about how often did you feel tired out for no good reason? *

3. In the last four weeks, about how often did you feel so nervous that nothing could calm you down? *

4. In the last four weeks, about how often did you feel without hope? *

5. In the last four weeks, about how often did you feel restless or jumpy? *

6. In the last four weeks, about how often did you feel so restless you could not sit still? *

7. In the last four weeks, about how often did you feel depressed? *

8. In the last four weeks, about how often did you feel that everything was an effort? *

9. In the last four weeks, about how often did you feel so sad that nothing could cheer you up? *

10. In the last four weeks, about how often did you feel worthless? *

Score

Total

The next few questions are about how these feelings may have affected you in the last four weeks. You don’t need to answer these questions if you answered ‘None of the time’ to all of the questions about your feelings:

In the last four weeks, how many days were you TOTALLY UNABLE to work, study or manage your day to day activities because of these feelings? *

[Aside from those days], in the last 4 weeks, HOW MANY DAYS were you able to work or study or manage your day to day activities, but had to CUT DOWN on what you did because of these feelings? *

In the last 4 weeks, how many times have you seen a doctor or any other health professional about these feelings? *

In the last 4 weeks, how often have physical health problems been the main cause of these feelings? *

Thank you for completing this form. If this has raised any difficulty for you please call Lifeline on 13 11 14 or the Mental Health Helpline on 1800 332 388. For a brochure on what to expect in our programs click here. If you would like to start practicing mindfulness and other psychological strategies for wellbeing while you wait for us to get back to you click here. You might also like to try the 'Take a Minute' challenge - improve your understanding of mental health and the little things you already do that boost your wellbeing: https://takeaminute.com.au/ Please note that if you have applied for a waitlist, it might be weeks or months before we have a course available so please see your GP if you need more immediate support.