Course Registration Form

Fields with an * are required

Thank you for your interest in attending a Mindfulness Program. To register, you will need to complete the following questions, so we can make sure the course will be a good fit for you. Once completed, your teacher will contact you a couple of weeks before the course to help you prepare, and to answer any questions. At any time feel free to contact us on admin@mindfulnessaus.com.au or phone 0488 064 228.

Please note: our FREE funded courses are available for Tasmanians over the age of 18 to support self-development and self-management of your mental health.

Before you give us your personal information, please read how we collect and manage your personal information, and indicate your Consent below.

Consent to Collect information and conditions of course participation

to help us deliver the course to you in an effective way, and
to provide deidentified statistical information to the National Minimum data set required by our funding body.

By filling out this form you consent to being contacted by MPA. The course is voluntary and you can withdraw at any time. Feedback, complaints and compliments can be given at any time using this online form, and are requested by our admin team during the course. Any concerns about the course facilitation can be sent to an MPA Director or the Director of Mental Health services, Primary Health Tasmania.

Our Policy Document for the Management of Personal Information by Mindfulness Programs Australasia (MPA) can be downloaded here. This document describes our responsibility in maintaining your confidentiality, and managing your personal information according to all legal requirements.

Consent: By checking the box below you acknowledge that you 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.

(If no, this is noted in the registration form) If you do not give consent, you can contact us and discuss other ways to participate in our courses.

I, (your name in Block Capitals)

First Name *

agree to the above conditions *

Your Details

Which course would you like to apply for? *

Were you referred to these courses? *

Please let us know how you heard about this program *

Have you done a course with us previously? *

NoYes

Can you tell us the year you did this course and who your teacher was? *

Year of Birth *

Phone Number *

Email Address *

Post Code *

Gender *

Country of Birth *

Main language spoken at home (if not English)

If English is your second language, what is your proficiency in spoken English?

Aboriginal and Torres Strait Islander Status. Do you identify as: *

Are you currently on a Mental Health Care Plan? *

Are you a participant in the National Disability Insurance Scheme (NDIS)? *

Do you have a Health Care Card? *

Do you identify as a veteran? *

Living arrangements *

Marital Status *

What is your employment status? *

Main income Source *

Wellbeing Questions

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

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:

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? *

The following questions ask about your quality of life – please tell us what best describes your situation as it has been over the past week:

Because of your health, your relationships (for example with your friends, partner, or parents) generally: *

Are very close and warmAre sometimes close and warmAre seldom close and warmI have no close and warm relationships

Thinking about your relationships with other people: *

I have plenty of friends and am never lonelyAlthough I have friends, I am occasionally lonelyI have some friends but am often lonely for companyI am socially isolated and feel lonely

Thinking about your health and your relationship with your family: *

My role in the family is unaffected by my healthThere are some parts of my family role I cannot carry outThere are many parts of my family role I cannot carry outI cannot carry out any part of my family role

Thinking about how you sleep: *

I can sleep without difficulty most of the timeMy sleep is interrupted some of the time, but I am usually able to go back to sleep without difficultyMy sleep is interrupted most nights, but I am usually able to go back to sleep without difficultyI sleep in short bursts only. I am awake most of the night.

Thinking about how you generally feel: *

I do not feel anxious, worried, or depressedI feel slightly anxious, worried, or depressedI feel moderately anxious, worried, or depressedI am extremely anxious, worried, or depressed

How much pain or discomfort do you experience: *

None at allI have moderate painI suffer from severe painI suffer unbearable pain

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.