Strictly Confidential

Wendy Jackson, Accredited Practitioner Mindfulness Now/ Teacher of Mindfulness Meditation Professional and Ethical Practice.

Wendy Jackson is committed to upholding the highest possible standards of professional ethics and codes of practice in the interests of client care and confidentiality. She adheres to the Ethical Guidelines of The British Association of Counsellors and Psychotherapists (BACP) and Mindfulness Now.

Client Name: _____________________________________Tel No/s__________________________________________________



Doctor: __________________________________________Surgery: __________________________________________________

Occupation: ______________________________________ Date of Birth: ______________________________________________

Contact Person: ____________________________________Tel No/s ________________________________________________

I acknowledge having agreed to Participate in an 8-Week Mindfulness course as dated below. No guarantee was given or implied. All information provided by me to my practitioner is accurate, to the best of my knowledge.

The practitioner will endeavor to ensure that sessions are conducted, as much as possible, at agreed dates and times. I will endeavour to attend as agreed and to provide reasonable notice (48 hours, if possible) in the event of being unable to attend. Any session recording or support material provided is free of charge, and only provided at the practitioner’s discretion.

If I have been requested by my practitioner to seek consent from my medical doctor/consultant then I have done so or will do so prior to treatment. Under extreme circumstances my practitioner may liaise, in writing or verbally, with my doctor and I may request a copy of any such communication. Session content is entirely confidential within legal boundaries.

I agree to move, or stretch, only to the extent that is completely comfortable for me and to stop immediately if I am feeling any discomfort.

Health related

What is your general state of health?

Do you or have you experienced any serious physical illnesses?

Do you or have you experienced any emotional /mental illnesses?

Do up you have any restrictions to physical movement, including stretching and walking?

Do you suffer or have you suffered from epilepsy (Epileptic seizures may be triggered byrelaxation) or from breathing difficulties, including asthma? If so written permission from your GP approving your participation on this course is required. If you do suffer from asthma do you use an inhaler and do you always have it with you?

Data Protection

I agree to the data protection policy as posted on the website of Surrey Berkshire


Course dates 16/10/19-11/12/19 (no class during half term 30/10/19)

Wednesday Evenings from 18:00-20:00.

Class held in upstairs room of The Easter Centre, Saint John’s Egham, TW20 9HR

Client Signature: ____________________________________ Date: __________________________________________________

Payment of £400 to be made via bank transfers or cash prior to course start date

First Direct (HSBC) Sort Code 40-47-63, Account 1257 0645

Send Registration to

Wendy Jackson

Surrey Berkshire Counselling

Runnymede Malthouse Business Centre

Malthouse Lane

Egham, Surrey

TW20 9BD