Registration Information | Mindfulness Training

Thank you for providing this information. We recognize the personal nature of these questions. This information helps us to understand and respond to participants’ individual needs. Please be assured the information provided is kept in strict confidence. All fields marked with an asterisk are required.

First Name*

Last Name*

Date of Birth*

Gender

Male

Female

Occupation*

Emergency Contact*

Relationship to You*

Phone*

Relationship Status*

Do you have children?*

Yes

If yes, how many?

Their ages?

Briefly describe the major stressors in your life. What brings you to the MBSR course at this time?*

Is there a specific condition or situation that inspires you to take the course at this time?*

Do you have a regular meditation, yoga or other practice that helps relieve stress?*

How committed do you feel to learning new practices? Are you able to dedicate approximately 30 minutes daily during the course to practice?*

Do you have anxiety, depression, or emotional health challenge? If so please describe:*

If yes, are you currently seeking professional care?

Yes

If yes, please list the professional(s) caring for you:

The MBSR Course involves learning new practices and approaches for working with stress, both physical and emotional. It is possible that through learning new practices and approaches for working with stress, you may require other supports, such as therapy, beyond what is offered through the MBSR course. As you are offered new practices, you will be reminded to self-monitor your participation – you may find your stress level increase temporarily when learning new practices and approaches for working with physical and/or emotional stress in new ways. It is your responsibility to identify when additional care is needed and to seek out such care independent from your participation in MBSR.