Neuroendocrine Cancer UK Mindfulness Self-Referral Form

Mindfulness Self-Referral Form

This 8 week Mindfulness Course has been developed in partnership with our counselling colleagues at Rareminds.

Rareminds was the first specialist, non profit, rare disease counselling and psychotherapy service to be established in the UK.

This interactive course is just for those affected by Neuroendocrine Cancer

(NET, Carcinoid or NEC))

and will be delivered via Zoom in a friendly, supportive group environment

with a maximum of 15 participants.

It involves in-depth and personalised teaching on

the practice and techniques of mindfulness including taught aspects,

discussions, exercises, and support for your own practice.

All self-referrals are treated confidentially

About You

First Name

Last Name

Contact phone number

Address: Town or City

Address: County

Address: Postcode

Which Mindfulness Course are you applying for?

About you or your family member / friend

Do you have neuroendocrine cancer?

YesNo

If No to the above question - what is your relationship to the person who has neuroendocrine cancer?

If Other: please state relationship

Your health and support

Have you tried Mindfulness before?

YesNo

If Yes - what was your experience? If No - do you have any questions or concerns about mindfulness?

What do you hope to gain from taking part in this mindfulness course?

Do you have any concerns about being able to attend all 8 sessions of this course?

YesNo

If you answered yes - please state concerns here

Is there anything you think it would be useful for the course lead to know about your physical or mental health before starting this course? If yes please give details here

Do you have any questions you would like to ask about the course before it starts? Please ask them here

Mindfulness Course Self-Referral Form

Please note completing this application form does not guarantee you a place on the course.

This will be decided by the course lead: who will contact you before the course starts.

Please keep in mind that emails can sometimes be treated as junk mail

and can be diverted to spam folders, therefore do check these when possible,

in case one of our emails has been diverted there.

Thank You.

Contact Information