HeartTouch Application

This questionnaire is asking information which is personal and private. Your responses will not be used for any purpose beyond the running of this workshop without your consent. Data collected will not be retained longer than necessary for the purposes of the workshop.

Please complete all of the fields. Thank you.

HeartTouch Application



First Name


Email Address

Tel / Mobile

Next of kin or contact details of anyone who we might need to contact on your behalf:


Workshop Title




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

2. Is it the right time? Would you say life is reasonably stable right now?

3. Does the workshop description stir up any emotions within you? To what degree?

4. One aspect of Mindfulness based work is exploring the capacity to be with our inner difficulty rather than making use of distraction / avoidance techniques. How do you feel about this?


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?


8. Are you open for giving and receiving therapeutic touch with a member of the opposite sex?

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


10. What is your level of health and mobility? Are there structural (eg. herniated discs), mobility or sensory (e.g. sound or light sensitivity) issues, that we might need to be aware of?

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.


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.


1. The workshop is a form of research, so we may want to publish articles following the event, which anonymously document details indicating the 'backgrounds' of the participants and the responses to the practices. The intention is to share this work with others who can benefit.

Are you okay with this?

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

2. Can we ask you to stop any activity if you realise it is not helpful in the moment or adjust it to meet your needs. This will be clear in live instruction also.

Is this okay?

3. Can we make an agreement with you, that you'll connect with one of us (however extreme the experience) and not just leave the workshop?

Is this okay?

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. Some of the practices involve physical touch through clothes similar to what might be experienced in a gentle Shiatsu treatment, although we are working within a Mindfulness and Compassionate Connection framework rather than a therapeutic one.

Are you okay about this?

Thank you!
Anthony Fidler

Contact Details Email: …….. Tel / Mob: ……..