Pre-program interview - Melbourne Mindfulness Institute

03 9629 3869 contact@melbournemindfulness.com

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Pre-program interview for group classes

Step 1 of 6

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Name*
Email*
Phone No*
Date of Birth*
MM slash DD slash YYYY

1. What is the reason you decided to enroll in this MiCBT course?
- a) To assist with stress?
- b) To assist with anxiety?
- c) To assist with depression?
- d) To manage chronic pain better?
- e) To improve general psychological well-being?
- f) Other (please specify):
Please select each of the following that applies to you:
Others
2. Are you currently receiving professional support or treatment for any of the above issues?
- Yes
- No
If yes, please indicate who is providing you with support:
- a) GP
- b) Psychiatrist
- c) Psychologist / counsellor
- d) Alternative or complementary therapies (e.g., natropathy, reflexology, acupuncture)
- e) Support group
- f) Other (please specify):
Other (please specify):
3. Are you currently taking any prescribed medication for a psychological issue?
- Yes
- No
If yes, please name the medication. Include Chinese, ayurvedic or herbal medicines.

4. Are you practicing any mindfulness or meditation exercises at present?
5. How did you hear about this MiCBT course?
6. Is there any other information you think is relevant to your participation in this course?

7. How important is it to you to learn these new skills or to improve your current skills? (scale of 1-100)
Please enter a number from 1 to 100.
8. Do you understand that you will have to practice the mindfulness exercises regularly if you are to benefit from the program?
9. Do you have any questions or concerns that you would like to raise?

Commitment to practice:
When in your day would be you be able to allocate two x 30-minute sessions for practicing mindfulness skills? The optimal practice time is around thirty minutes twice a day.
You will need a place for practice that is quiet and where you will not be interrupted. Where in your home or workspace could you establish this? (e.g., bedroom, study, garage, own office, lounge)

Are you happy for us to use your de-identified data for research purposes?
- Yes
- No
Consent*
I am willing to commit to the following:
- To arrive punctually for all sessions
- To do the practice exercises between sessions
- To share my experience and to treat the experiences of others with respect and confidentially
- To attend all sessions
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LOCATION

Suite 314, Level 3,
530 Little Collins Street,
Melbourne 3000.

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OFFICE HOURS

Monday - Friday: 9:00 – 18:00
Some Saturdays & Evenings by arrangement
Sunday: Closed

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CONTACT

Phone: 03 9629 3869
Fax: 03 7000 5017

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