DEPARTMENT OF PSYCHIATRY

OXFORD MINDFULNESS CENTRE

Mindfulness-Based Cognitive Therapy (MBCT)

8 Week Online Course via Zoom

“Mindfulness is the awareness that emerges through paying attention on purpose,

in the present moment, and non-judgmentally, to things as they
are.”

WILLIAMS, TEASDALE, SEGAL, AND KABAT-ZINN (2007)

This 8-week online course is intended for anyone wishing to enhance their general
physical and mental wellbeing.
If you are experiencing symptoms of low mood, stress or anxiety, either at work or at
home, this course could offer you some skills in how better to respond to the 'ups and
downs' we are all facing, especially in these current times of difficulty. This program is not
being offered as a treatment for any specific physical or psychological conditions. It is also
not suitable for people who are currently experiencing severe psychological or
physiological conditions. For further information please refer to the resources available on
the Oxford Mindfulness Centre
(OMC) site: https://oxfordmindfulness.org/for-you/issues-landing-page/

The course is offered for free by University of Oxford student, Beverley Hilsden, in partial
fulfilment for the completion of the requirements for the ‘Master of Studies in
Mindfulness-Based Cognitive Therapy. As a master’s student I am supervised by an
experienced and registered MBCT instructor, who is also affiliated with the OMC.

https://www.conted.ox.ac.uk/about/mst-in-mindfulness-based-cognitive-therapy
Personal Information:

Forename: Mery
Middle name (optional): Arsih
Family name: Sunarno
Address: Karanganyar, Jawa Tengah
Country: Indonesia
Postcode: 57792
DOB:
Occupation: Indonesian
E-mail: merryarsih99@gmail.com
Confirm e-mail: merryarsih99@gmail.com
Mobile: +6281215722752
Please provide the name and telephone number(s) of an emergency contact person:
Muhammad +6281229549547

Do you have a physical or sensory limitation which might affect your participation?
No

Please confirm that you have read the information provided under the heading:

“Is this the right course for me?” √

Health Questions:

The health declaration information you provide is used to assess your suitability for this
course. It is kept as confidential and is available to the Department of Psychiatry/ ‘Master
of Studies’ academic staff, University of Oxford and the recruiting student, who may need
to contact you for further discussion.
"I undertake to be responsible for my own wellbeing during the course and agree to bring
any concerns to the course teacher in the first instance, and contact my GP or relevant
health professional, should I continue to have concerns about my wellbeing." √

Following the submission of your pre-course questionnaire, you may be contacted by the
Course Lead to discuss if the course is appropriate for you to attend at this time, and to
confirm whether you have been offered a pre-assessment interview:

Do you have Diabetes Type 1? Y x N √

Have you experienced depression inx the past 6 months? Y N√
Are you currently experiencing depression? Y N √ Not sure
Have you experienced psychotic episode/s in the past? Y N √
Have you experienced a manic/hypomanic episode in the past 6 months? Y N √
Not sure
Are you currently receiving any psychiatric or psychological treatments? Y N √
Are you currently taking any medication? Y N √
Are you currently receiving any talking therapy or counselling? Y N √
Have you deliberately harmed yourself in the past year? Y N √
Have you ever attempted to take your own life? Y N√
Have you ever experienced a severely traumatic event which is currently affecting you?
Y N √ Not sure
Have you experienced bereavement in the past year? Y N √
Are your currently using alcohol or drugs in order to manage your stress/distress? Y
N√
Are there any current life changes (loss of home, job, relationship breakdown, too many
work commitments etc.) that may be placing you under additional stress? Y √ N

What do you hope to gain by attending the course? I hope I can more can accept my life and
I want to improve my well being.
Equality & Diversity:

As a University of Oxford student, I follow the policy on Equality and Diversity, to foster an
inclusive culture which promotes equality, values diversity and maintains a working,
learning and social environment in which the rights and dignity of all its participants,
students and staff are respected.
The diversity information you provide is kept as confidential and will be anonymized for
any research or statistical analysis. It is kept in accordance with the General Data
Protection Regulation (GDPR).
What is your gender? Female

What is your age? 25

What is your ethnic group? Javaness (Asian)

Terms & Conditions:

The sessions will be recorded using the online platform, Zoom.  The recordings are used
for assessment purposes only. Please feel free to speak with me, if you have any concerns
about this.

I confirm that I have read the Terms and Conditions. √

The Department of Psychiatry, Oxford, may wish to send you information about their
services or request feedback on our services. Please tick this box if you are happy to be
contacted. √

Support the Oxford Mindfulness Foundation!

The OMC Foundation works to promote good mental health and resilience through
mindfulness. To do this, they are actively working to bring the benefits of Mindfulness-
Based Cognitive Therapy to groups who are currently underrepresented in the
mindfulness community. As an independent not-for-profit charity, they rely on donations
to do this. Please consider adding a donation to support this aspect of their work:

https://www.development.ox.ac.uk/page.aspx?pid=3110

Thank you

This form has been adapted from information provided by the OMC.