HeartTouch Application Form

personal

Title

First Name

Surname

Nationality

My_time

Email Address

Tel / Mobile

Emergency or support contact: Please give the name, relationship and contact details of someone we may contact on your behalf if we are concerned about your wellbeing during or following the workshop.

workshop

Workshop Title

Presenter

Date

general

1. What is your interest in attending this workshop? What do you hope to achieve from attending?

2. Would you say that your life is reasonably stable at present? Is there anything happening at the moment that might affect your participation in the workshop?

3. When you read the workshop description, do any aspects bring up strong emotions or concerns for you? If so, please tell us anything that you think would be helpful for us to know.

4. Some of the practices involve gently noticing and staying present with difficult sensations, feelings or emotions, rather than immediately distracting ourselves from them. How do you feel about exploring this approach?

experience

5. Do you have any experience of Mindfulness / Meditation based practices? If yes, how did you get on?

6. Do you have experience of other practices such as qi gong / yoga / dance / martial movement work? If yes, how did you get on with them?

7. Do you have any experience of giving and/or receiving compassionate / therapeutic touch?

boundaries

8. Are there any preferences or boundaries concerning who you would feel comfortable giving or receiving touch with?

9. Are there any sensitivities around touch that it would be helpful for us to know about?

physical

10. Do you have any mobility, physical or sensory needs that may affect your participation, or anything we should know so that practices can be adapted appropriately?

support network

11. How is your emotional support network?

12. Do you have support from significant others around you? Are they aware of your interest in the workshop?

13. Are there friends or professionals you can turn to if there is a need to continue processing emotional material beyond the scope of the workshop?

professional experience

14. If you work within the mental health field, can you give some details of your professional background.

other

15. Finally, any other information that may be useful to help us, both in terms of knowing whether it's the right time and in guiding the workshop if you attend this time.

consent

1. We may evaluate HeartTouch workshops to help us understand participants' experiences and develop the work. We may also publish or share findings about participants' backgrounds, experiences and responses to the practices. Any information used in this way will be anonymised.

Is this okay? Yes No

We understand that participation in a group can sometimes trigger distressing inner material.

2. Can we ask you to stop or adjust any activity if you realise it is not helpful for you in the moment? We will also make this clear during the workshop.

Is this okay? Yes No

3. Do you need some kind of private signal in case of distress or are you happy to ‘catch our eye’ and quickly chat outside the group space?

4. Can we ask that, if you feel you need to leave the workshop, you connect with one of us first, where possible, however difficult or intense the experience may feel?

Is this okay? Yes No

5. Can we have your permission to contact the person you have provided as your emergency/support contact if we have a significant concern about your wellbeing or safety?

Is this okay? Yes No

6. Some practices may involve gentle physical touch through clothing. Participation in touch practices is always optional. You can decline, stop or modify a touch practice at any time without having to give a reason.

Are you comfortable participating on this basis? Yes No

Thank you!
Anthony Fidler