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Pre-course Questionnaire
Introduction to Meditation & Mindfulness | Saturday Nov. 6, 2021
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Email
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Best phone number to reach you?
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Your Full Name
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What is the name you prefer to be called for this course?
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Gender Identity (select all that apply)
Man
Woman
Transgender
Non-binary/non-conforming
Prefer not to respond
Your pronouns
He/him
She/her
They/them
Sie/hir
Other:
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What is your age group?
18-24
25-34
35-44
45-54
55-64
65-74
75 +
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Which of the following best describes your race and/or ethnicity?
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Black or African American
Hispanic or Latino
Native American or Alaskan Native
White or Caucasian
Multiracial or Biracial
A race /ethnicity not listed above
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What is the level of education you have completed?
Less than high school diploma
High school degree or equivalent (e.g. GED)
Some college, no degree
Associate degree (e.g. AA, AS)
Bachelor's degree (e.g. BA, BS)
Master's degree (e.g. MA, MS, Med)
Professional degree (e.g. MD, DDS, DVM)
Doctorate (e.g. Ph.D., Psy.D., Ed.D.)
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Marital Status:
Single (never married)
Married, or in a domestic partnership
Widowed
Divorced
Separated
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What is your household income?
Below $25,000
$25,000 - $50,000
$50,000 - $100,000
$100,000 - $200,000
Above $200,000
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If Registering for CE credits / hours, select all that apply for your licensure(s)
APA
NBCC ACEP
NASW - MA Chapter
MA DESE
Is there anything that we would need to know about your health or abilities to better support you in this course?
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Do you have any past experience with meditation or mindfulness practices?
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How did you hear about this event?
Facebook/Instagram
Email
Internet
Friend/Word of mouth
Visiting our website
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If the occasion arises, do you consent to your photo being taken for the purpose of marketing and potentially displaying the photo on our website?
Yes, I consent.
No, I do not consent.
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Waiver
Please electronically sign below by typing in your full name, acknowledging that you read and understand the waiver and its statements.
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