Name
*
First Name
Last Name
Email
*
Phone Number
*
If needed, is it ok to leave a voicemail on the phone number you listed?
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Yes
No
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Name
*
Emergency Contact Phone Number
*
How did you hear about the MBSR program? (Please specify)
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Date of Birth
*
MM
DD
YYYY
I confirm I am 19 years of age or older
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Any previous meditation experience?
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I confirm I have registered for or have completed the INTRODUCTORY CLASS
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Yes
No
Date you completed or are registered for the INTRODUCTORY class:
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MM
DD
YYYY
What do you consider to be your strengths? (please list at least three)
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Do you have close friend(s) and/or family in the area?
*
Yes
No
How is the quality of your sleep? (please describe)
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Family Doctor
*
Do you take prescription medication? (If yes, please list)
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Currently seeing a counsellor or psychologist?
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Yes
No
Have you experienced any recent and significant changes due to
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Medical/Health Matters
Psychological Matters
None
Any previous overnight hospitalizations?
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Yes, for medical/surgical reason(s) only
Yes, for psychological reason(s) only
Yes, for both medical/surgical AND psychological reasons
None
Have you experienced any of the following in the past (check all that apply):
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Do you have a history of substance abuse?
*
Yes
No
Do you have a history of trauma?
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Yes, and currently experiencing symptoms.
Yes, but I do not have symptoms currently.
No.
Anything else you want me to know:
Payment Options for this MBSR Program:
*
Please Choose Method of Payment
*
REFUNDS: Refunds for this MBSR program are provided for cancellations made prior to session #1, less a $50 processing fee. After that, unfortunately no refunds will be issued unless there is an emergency. Thank you for your understanding.
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Please note: Applications will be processed within within 24 hours.
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Technology Requirements: participation in this program requires internet connection and a device (phone or computer) with access to video, speakers and mic. Do you fulfil these requirements?
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Yes, I meet all technology requirements
No, I don't meet all technology requirements
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