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Mindfulness Based Programs Participant Background Form
If you would prefer to answer any of these questions via HIPAA compliant, encrypted email, please indicate that in the question response area below and email your response here:
https://hushforms.com/tracy.ochester
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Email
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Your email
Today's Date
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MM
/
DD
/
YYYY
What is your mailing address and phone number?
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Your answer
First and Last Name
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Your answer
What are your personal gender pronouns?
Your answer
What is your occupation?
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Your answer
Which Mindfulness Based Program are you registered for?
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Mindfulness Based Stress Reduction (MBSR)
Mindfulness Based Cognitive Therapy (MBCT)
Mindful Self-Compassion (MSC)
Mindfulness Based Relapse Prevention (MBRP)
How are you participating in the course?
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On site
Online via Zoom
How did you hear about the this course? Please be as specific as possible.
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Your answer
Why are you interested in participating in this program?
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Your answer
Can you please tell us a bit about your mindfulness and self-compassion experience, if any?
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Your answer
Are you coping with any physical or mental health concerns or currently taking medication for physical or mental health reasons, that may affect how you feel from one week to the next or impact your participation or mobility? If yes, please explain.
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Your answer
Have you had any traumatic experiences in your life or have you experienced any recent losses or life changing events?
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Your answer
Have you experienced suicide thoughts any time in the last year?
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Yes
No
Can you commit to attending all meetings and participating fully? (please list any potential barriers or disruptions here - if you anticipate missing more than 2 meetings, we suggest you enroll at another time)
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Your answer
What personal resources are you willing/able to draw upon if you experience struggles or challenges during the course? (for example a therapist, spiritual advisor, close family or friends, etc.)
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Your answer
If you have any special needs for which you would like to request accommodation, please share those needs here.
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Your answer
Anything else you would like us to know?
Your answer
Thank you - the teacher will contact you if they have any questions.
If you have any questions, please email us at
info@mindfulness-alliance.org
Send me a copy of my responses.
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