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MBSR Registration Form
MBSR Starts July 31, 2023. After registration you will receive more info including Zoom links.
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* Indicates required question
Email
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Your email
First Name
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Your answer
Last Name
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Your answer
Phone
*
Your answer
City, State
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Your answer
Why are you interested in attending this program?
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Your answer
Do you have a regular practice of meditation? If so, what type and how long have you been practicing? (It's not necessary to have any experience of meditation prior to this program.)
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Your answer
How would you describe your physical health?
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Your answer
Are you currently in psychotherapy?
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Yes
No
If you answered "yes" to the previous question, we may need to speak with your therapist. Please provide the name and telephone number of your therapist.
Your answer
Are you currently taking psychoactive medication, or any medication that may affect how you feel from one week to the next? (If so, please provide details).
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Your answer
Is there anything else that it would be helpful for the instructors to know at this time? Thank you for answering these questions.
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Your answer
Payment options
. Please pay at a level that is most comfortable for you. No one will be turned away for lack of funds.
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Level 1 - $250
Level 2 - $200
Level 3 - $150
Level 4 - $100
Level 5 - $50
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