Mindful Mentoring Booking Form

We are pleased that you have decided to book onto our Mindful Mentoring course.

Please complete the following as fully as possible.

Your detailsName

DOB

Address

Tel no

Email

Ethnicity Gender

Additional support needsDo you consider yourself as experiencing any of the following (please tick all that apply):

□ At-risk of developing poor mental health □ Social isolation□ Diagnosed mental health difficulties□ Learning difficulties□ Long-term physical health issues□ Other disability issue□ Substance misuse issues□ Ex-Offender or at risk of re-offending□ Homelessness□ Other (please state)………………………………………………………………..

If any of the above have been ticked, please provide further details here:

During the taster day and course, all attendees are able to access support from our Mentor who will work alongside the course trainer. Is there anything that we can do during the taster day and / or course to ensure you are comfortable and fully able to participate?

Signed……………………………………………………………...…Date......................

Thank you for your booking. Please return by email to:Jit Singh

Project ManagerMindful Mentoring

Email: info@go-getta.org.uk