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Integrative Pathways to Healing

Holistic Health Education, Mindfulness, Yoga Therapy

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Registration Questionnaire

Thank you for filling out the forms to the best of your ability. We realize the personal nature of the information, and assure you that completed forms are kept in the strictest confidence.

MBSR Registration — Spring 2019

First Name *

Last Name *

Address *

City *

State

Zip Code *

Daytime Phone

Cell/Evening Phone *

How did you hear about us?

Age *

Male

Female

General Information

Please describe what you consider to be stressful in your life, i.e. job, relationships, a chronic or life threatening illness, etc. *

What are your greatest worries and stresses? *

What are the current ways you use to try and manage stress?

Helpful stress management *

Not helpful stress management *

MBSR Program Registration

Please rate your overall stress level at this point in your life using a 1-10 point scale. 1 = stress free and 10 = stressed to the max *

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.” *

What target goals would you like to set for yourself in taking this program? Please try to list at least 3. *

What do you care about most in your life? *

What gives you pleasure? What do you enjoy? *

What are your greatest hopes? *

Are you currently involved in a specific medical treatment or psychological counseling program? Please list any current medications. *

Please list any hospitalizations, surgeries, or injuries with dates. *

Please describe any complementary or alternative treatments you have received or are receiving. *

Please describe your physical health right now. *

Please describe your sleep quality. *

Please describe your emotional health. What are your biggest emotional challenges? *

Please describe your spiritual health. *

What is most challenging spiritually? *

How do you feel about the future? *

Please describe your support system. *

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.? *

Please add anything else that you feel may be important for the instructor to know about your situation. *

Thank you very much for completing these questions.

I agree to pay a $50.00 deposit. I understand the the full price of the course is $450.00

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“It’s cheaper to promote health than to maintain people in sickness.”

— Florence Nightingale

“Be the change you wish to see in the world.”

— Gandhi

“The natural healing force within each one of us is the greatest force in getting well.”

— Hippocrates

“Caring for others requires caring for oneself.”

— Tenzin Gyatso the 14th Dalai Lama