Mindfulness-Based Stress Reduction – Participant Intake Form - Acupuncture, Massage, Mindfulness, Traditional Chinese Medicine: Victoria

Mindfulness-Based Stress Reduction – Participant Intake Form

Welcome to the MBSR program! Thank you for your time in completing this form so that I can provide a supportive learning experience. All information shared here will be completely confidential and will only be read by me (Stephanie Curran).

Name*

First Last

Best phone number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Occupation

Emergency contact name & phone number

How did you hear about this course (please be as specific as possible)?

Please tell me a little about yourself and what brings you to this class at this time. Briefly describe any major stressors, worries or concerns in your life.

What are three ways you hope to benefit from this course?

Do you have anxiety or depression, suicidal episodes, post-traumatic stress or active drug/alcohol dependency? If so, please describe and list any supports you have worked with in the past or are currently engaged with now.

Are there any health conditions or physical limitations that are a concern for you? Or may interfere with your ability to fully participate in the mindful movement/gentle yoga (stretching) portion of this course? If yes, please describe and share what adaptations you might need.

On a scale from 1 to 10 how certain do you feel that you can commit to approximately 45min minutes of daily practice, 5-6 days a week while you are in the program? Please select a number.

** Please take a moment to mark all sessions in your calendar **, including the full day retreat. Are there any dates you know in advance you will miss class?

I can attend all sessions

I know I will be missing a class. *please list date(s) with conflicts below

Please list the dates of the classes you will miss.

Deposit

Price:

Payment Method

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

“You have such a beautiful, calm, grounding presence and your voice is so soothing. I really enjoyed the workshop. I’ve found the mindfulness awareness trickling into my everyday life these past two weeks which has been really cool.”

JC, spring session participant (2019)