First Name
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Last Name
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Address
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City
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State
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Zip Code
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Email
Daytime Phone
Cell/Evening Phone
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How did you hear about us?
Age
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General Information
Please describe what you consider to be stressful in your life, i.e. job, relationships, a chronic or life threatening illness, etc.
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What are your greatest worries and stresses?
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What are the current ways you use to try and manage stress?
Helpful stress management
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Not helpful stress management
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MBSR Program Registration
Please describe any previous experience you have had with stress reduction, meditation, relaxation, yoga, mindfulness, imagery, and other mind-body approaches to healing and health. If you have not had any prior experience, please write, “No experience.”
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What target goals would you like to set for yourself in taking this program? Please try to list at least 3.
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What do you care about most in your life?
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What gives you pleasure? What do you enjoy?
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What are your greatest hopes?
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Are you currently involved in a specific medical treatment or psychological counseling program? Please list any current medications.
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Please list any hospitalizations, surgeries, or injuries with dates.
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Please describe any complementary or alternative treatments you have received or are receiving.
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Please describe your physical health right now.
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Please describe your sleep quality.
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Please describe your emotional health. What are your biggest emotional challenges?
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Please describe your spiritual health.
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What is most challenging spiritually?
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How do you feel about the future?
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Please describe your support system.
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At the completion of this class, imagining that you do learn everything that you want to learn, how would you like to experience yourself? For example how do you want to be feeling in your body? How do you want to be experiencing your mind, your emotions, your connections with other people, etc.?
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Please add anything else that you feel may be important for the instructor to know about your situation.
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Thank you very much for completing these questions.
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