MINDFULNESS-BASED STRESS REDUCTION (MBSR) Intake Questionnaire (Fall/Winter 2023)

Thank you for filling out this form. We realize the personal nature of these questions. Please be assured that the forms will be kept in strict confidence and in compliance with HIPAA laws. The information you provide will be of great help to us in assisting you with common issues that may arise.

 Please note that this questionnaire will be held by Dr. Chiaramonte and that the information contained will never be shared with anyone. No record shall be kept after the course.

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Email *
First Name
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Last Name
 *
Telephone number where we can reach you or leave a message in case of class changes.
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Full Address, including zip code (you will receive the course manual by Fedex)
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Are you affiliated with Stony Brook University (SBU)? *
If you are affiliated with SBU,  what is your role/position?
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What is your profession?
 *
Are you affiliated with the World Trade Center Health Program (WTCHP)?
 *
Required
What is your relationship status?

Where did you learn about the MBSR course?

*

 Please list current significant medical problems/concerns

*
Are you currently in psychotherapy? *
If you are in psychotherapy, please briefly describe your condition and anything you think is relevant for Dr. Chiaramonte to know in order to be attuned to your situation.  
Have you been diagnosed with Post-Traumatic Stress Disorder (PTSD)? *
If you are in psychotherapy, is your therapist aware that you will be taking the MBSR course? 

If not, please consider letting your psychotherapist know that you will be taking the course as this course involves an ‘inward journey’ that is relevant to and synchronistic with psychotherapy.

 *

Do you have difficulty falling or staying asleep? Do you wake up earlier than you would like?   

*
How many times per week do you drink alcohol?  *
Do you use recreational drugs such as marijuana? *
If you have a history of alcohol or drug abuse or addiction, please describe.  *
What are your greatest worries/stressors? *
What brings you the most pleasure in life? *
Do you have experience with meditation? *
Any experience with yoga? *
If you have experience with meditation and/or yoga, please describe.
 *

Please list 2 or 3 personal reasons you have for taking the MBSR course.

*
What do you hope to get out of the course? *

Is there anything else that you would like the instructor to know?

 *
Thank you for completing this questionnaire.
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