8-Week Mindfulness-Based Stress Reduction Application Form: Journey to Well-Being
By filling in this form, you will enable me to maximize my effectiveness as your instructor. 
Please answer all questions. The information you provide will be confidential and reviewed only by me. 
I hope the experience of this program will be a beneficial one. On receiving the application, Dr. Yowon Choi (instructor) will contact you to set up an interview.
  • Place: You&Me Psychological and Counseling Services at Pyeongtaek Office
  • Fee: Insurance Holders Only (** Insurance information required)
    Please send send your insurance card pictures back and forth by email(adminpt@ypcskorea.com).
  • Schedule: From May 13 to July 1. Monday evenings, 18:00-20:00. A day of silence on June 22, from 9:30-16:30
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Name *
Gender *
Date of Birth *
Age *
Occupation / Work status *
Email *
Phone Number *
Address *
Name of contact person and phone number in the case of an emergency *
Relationship Status *
Are you currently under medical treatment or supervision for physical conditions or illness? *
If yes, please describe.
Are you currently in treatment with a therapist or psychiatrist?
 *
Required
If yes, please describe:
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Are you currently taking any prescription medications for physical or psychological
conditions?
 *
Required
If yes, please list each medication and daily dosage, as well as the condition it is being used
to treat.
 *
Could you share any physical or mental health conditions you are currently experiencing or have dealt with in the past? Please include how these conditions impact your daily activities and overall quality of life.
 *
Quality of sleep/How many hours:
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What kind of exercise do you manage to do each week? How many times a week?
 *
Caffeinated drinks per day:
 *
Alcohol use/dose; frequency:
 *
Recreational drug use/dose; frequency:
 *
Cigarette smoking/dose; frequency:
 *
History of substance abuse, if relevant:
 *
Do you have thoughts of ending your life?
 *
Required
What do you care about most? (Write top 3)
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What gives you the most pleasure in your life? (Write top 3)
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What are your greatest anxieties? (Write top 3)
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Have you heard or experienced mindfulness meditation? What do you think mindfulness
meditation is?
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Let us know if there are specific areas of your well-being you hope to improve through participating in the Mindfulness-Based Stress Reduction (MBSR) program.
 *
Is there anything else that you might want me to know about you?
 *
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