Application Form: Group Leader Training (Mindfulness Training for Primary Care)

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Thank you for filling out this application form! After you have filled out this form, a member of the CMC staff will get back to you by October 1, 2019 about any questions, and with a registration link. You may get in touch with us any time at cmc@challiance.org or 617-591-6132. Thank you!

Email *

First name *

Last name *

What is a good phone number to reach you at?

Please describe yourself in a couple sentences.

What is calling you to attend this training? (3-5 sentences)

What is your mindfulness / meditation experience? Please describe as it feels appropriate to you. Please also include types of practice, app or website use, years of practice, any experience taking an 8-week mindfulness intervention, any retreat experience, and average daily practice type and time.

What is your current occupation?

What is your age?

How do you identify your race?

How do you identify your ethnicity?

How do you identify your gender?

Are you a CHA staff member? If so, what is your role at CHA?

Are you interested in leading MTPC as a clinical intervention (and plan to bill these groups to insurance)? If so, what is your current employer and what clinical training/license do you have?

Have you completed an 8-week MBSR course as a participant? If so, where, and who were your teacher(s)?

How many sessions of the 8 weekly MBSR sessions did you attend?

Did you attend the MBSR all-day retreat?

Are you able to commit to 6 months of daily practice following the Group Leader training?

Have you had any experience leading mindfulness or mind-body interventions before?

Have you had any experience leading groups in clinical settings before?

Are you interested in the training with an intention to lead in OBOT (Office-Based Buprenorphine Treatment) settings?

Yes

Other:

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Please tell us how your taking this training may impact your community/healthcare system

Please describe your specific aspirations for making mindfulness accessible to vulnerable populations

What are your hesitations or fears about attending this group leader training?

Are you applying for a scholarship to attend this training? (apply at www.chacmc.org/scholarship)

Yes

Other:

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I am CHA staff or staff of a CMC grant-partnering institution and I agree to lead 2 MTPC groups as a clinical intervention with weekly videoconference supervision with CMC staff during the groups. In exchange, CMC will cover my registration cost for MBSR (if applicable) and MTPC Group Leader Training. (If you are unsure, please contact cmc@challiance.org.) *

I agree.

I disagree. (Please describe below any barriers or difficulties that you foresee.)

Required

Please describe briefly here.

Thank you for filling out this application! You will be contacted by a member of our staff with any follow-up questions, and the link for registration. Anything you'd like to add here?

Submit

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