Training Programme Application Form

If you have any questions about completing this form, email us on info@breathworks.co.uk or call 0161 834 1110
Training Programme Application Form
If you have any questions relating to this form, email info@breathworks.co.uk or
Please tell us which training level you are applying for
Training Level - unused *
If you have done TTi and are registering for your TTa training event, go to the registered students option under the Teacher Training drop down menu on our website.
Training Level *

Introductory Teacher Training (TTi) Advanced Teacher Training (TTa)
If you have done TTi and are registering for your TTa training event, go to the registered students option under the Teacher Training drop down menu on our website.
OpenCRM Event
Please specify all of the dates that you are available to attend. Once your application has been accepted we will confirm the course date with you.
Residential Retreats

None available at present Other
Non-residential Modular Training Dates:

Mar 7-9, Mar 21-23 2022, Manchester July 25-27, Aug 22-24 2022, Manchester
Online Training Dates (Introductory Training only):

28 Feb - 31 Mar 2022 26 Apr - 26 May 2022 6 June - 7 July 2022 5 Sept - 6 Oct 2022 31 Oct - 1 Dec 2022
Please select which online orientation workshop dates you can attend, ensuring it is at least 2 months prior to your training event wherever possible:

Wednesday 5 January at 4-6pm Wednesday 2nd February at 4-6pm Sunday 6th March at 2-4pm Wednesday 6th April at 4-6pm Sunday 22nd May at 2-4pm Wednesday 6th July at 4-6pm Sunday 14th August at 2-4pm Wednesday 14th September at 4-6pm Sunday 6th November at 2-4pm Wednesday 7th December at 4-6pm
Please tell us some basic information
Please upload a head & shoulder photo of yourself so we can easily identify you when you come along to our training:
Cancel of
Name: *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
example@example.com
E-mail 2
example@example.com
Mobile Phone *
Home/Work Phone
Date of Birth - unused

Month Day Year
Date of Birth *

Day Month Year
Gender *
Ethnicity *
Please tell us about your practice
In order to participate in the Training Programme, we ask that you are familar with Breathworks and have an established daily mindfulness practice. Please tell us which of the following you have participated in and how long you have been practising.
Courses Attended *

Breathworks Living Well with Pain and Illness / Mindfulness for Health 8-week course Breathworks Mindfulness for Stress course An 8-week MBSR/MBCT course (does not count as a pre-requisite) Breathworks for MBSR/MBCT Teachers 3-day course Breathworks 5-day residential Mindfulness for Health course (previously Immersion Retreat) Other
Please state the year you attended the course and the course provider (organisation/teachers name): *
Please provide contact details for the organisation/teacher who provided the course: *
If you have provided contact details above, would you be happy for us to contact this person for a reference?

Yes No Other
Have you ever been on a residential retreat?

Yes No
Length of practice *
We'd like to know about your experience and practice of mindfulness. Please share a bit about why you practice, what context you practice within (professional, religious, self-led, etc.), the types of practices you do, and what your daily practice looks like.
Why I practice mindfulness *
Practice context *
Types of practice *
Daily mindfulness practice *
Please tell us a bit about your process of how you work with your own experience of pain, stress or illness or any other kind of suffering, both in meditation and in your daily life. *
Do you currently have any physical health conditions? *
If yes, how does this condition affect your ability to hear, see, sit, stand, walk or engage in mindful movement?
Have you had any mental health issues within the last few years (such as anxiety or depression)? *
If yes, have you ever, or are you currently receiving treatment?
Is there anything else you'd like to share with us?
Reasons for applying
Please tell us a bit more about your reasons for applying to the Training Programme. What do you hope to get out of participating and how does this apply to your personal and professional goals?
Reasons for applying *
How do you hope to make use of your training? *

To enhance my personal practice To incorporate mindfulness into my work with patients or clients To lead Breathworks courses in my place of employment To lead Breathworks courses as an independent mindfulness teacher Other
Please tell us if you have trained to teach any of the following:

MBSR MBCT DBT (Dialectical Behavioral Therapy) ACT (Acceptance and Commitment Therapy) Other
Please can you tell us why you want to train with Breathworks?
Please tell us a bit about your educational background ie degrees, professional qualifications or other certificates earned:
Educational background *
Please tell us about any additional training or experiences you have had that you feel are pertinent to this application:
Additional Training/ Experience *
Please tell us a bit about your work experience, ie the field you are in, jobs held, client-type etc.
Profession *

Registered Nurse General Practitioner Occupational Therapist Physiotherapist Other Healthcare professional Therapist Counselor Psychologist Other Mental Health professional Holistic Therapist (eg yoga teacher, massage therapist etc.) Mindfulness Teacher Teacher/Lecturer Researcher Other Educational professional Other
Work Experience *
Personal Requirements
If attending a residential retreat, please note that accommodation may be in a room with up to 3 other people of the same gender. Single rooms are limited. If you have a medical condition such as insomnia and require a single room, please provide details below:
Do you require a single room? (please be considerate of the fact that we have very few single rooms and we try hard to allocate them to those who are particularly in need due to medical conditions) *

No Yes
Reason for a single room
All meals provided will be vegetarian. Please tell us if you have a dietary requirements for medical reasons:
Dietary requirements
If you have particular access or communication requirements which need to be met in order for you to engage fully with the Breathworks training programme (eg. related to dyslexia, physical or mental health conditions, sensory impairment, restricted mobility etc). Please give details:
Please provide contact details for who we should contact in case of an emergency when attending a programme with us.
Emergency Contact Name *
Emergency Contact Phone Number *
If there is an incident/accident/ flare up of your health condition during one of our events, is there anything we need to know to help get you the support you will need? eg list of medication, usual steps you take
Payment Information
Please select the rate you will be paying:

Individual Organisation Concession
Enter Discount Code (Optional - if you have a valid discount code this will be applied if your application is accepted)
Payment Option
Payment Method

Full Deposit
Deposit
We provide concessionary rates for people with significant financial hardship. If selecting to pay a concessionary rate, please tell us more about your financial situation.
Financial Situation
Keeping in touch
How did you hear about Breathworks *

Friend / family member Doctor / hospital Work / Work Colleague Internet Search Facebook Twitter Magazine Advert Leaflet Other (please specify)
Communication Preferences

Tick this box to receive our email newsletters relating to Breathworks and Mindfulness that we think you may be interested in.
Newsletter sign up
Newsletter
Tick this box to receive on going support communications to help support your practice and on going training including mindfulness events, research, offers and discounts.
Ongoing support communications sign up
Ongoing support
• This contact will always come from Breathworks CIC
• You will receive approx 1-2 emails per week.
• We will never sell or pass your details to other organisations without your consent.

Privacy & Cookies Policy
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Submit your application
Please read the terms & conditions of the training programme by following the link below and click to confirm your agreement. If you are then ready to submit your application, click the submit button below for your application to be sent to a member of the Breathworks team. We will be in contact with you once your application has been reviewed, which may take up to 4 weeks.
Please answer the question below to show that you're not a robot:
Activity subject
Date of submission

Month Day Year
Contact Type
Activity status
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Please tell us which training level you are applying for

Please tell us some basic information

Please tell us about your practice

Reasons for applying

Personal Requirements

Payment Information

Keeping in touch

Submit your application