Mindfulness Based Stress Reduction
Date: Saturdays  January 8, 2022 - March 5, 2022
Time: 6.30pm - 8.30pm (IST)

Orientation: Friday January 7, 2022 7:00 - 8:00 pm (IST)

Half-day retreat: February 19,  5:30pm - 9:30pm (IST)

Hosted By: Pallavi Jois

Please answer the questions below. By doing so, you will enable us to maximize our effectiveness as instructors. We will send you an email with the Zoom link to join the sessions.
 
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Email *
First Name *
Last Name *
Date of Birth *
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YYYY
Phone *
In case of emergency, Contact Name and Phone # *
Name of primary care physician and phone # *
Are you currently under medical treatment or supervision? *
If yes, please explain *
List medications and dosage *
Quality of sleep (How many hours) *
What exercise do you do? Frequency? *
Do you smoke? If so, how many per day? *
How many caffeinated drinks per day? *
Alcohol or recreational drug use: frequency *
History of substance abuse (if relevant) *
Are you currently undergoing therapy for mental health? If yes, please explain. *
Name of therapist and phone # *
Why do you want to join the MBSR program?
What are your goals?
Is there anything else you want us to know about you? *
I commit to participating in all the sessions each week, and to treat myself, my facilitator, and my group with kindness. The commitment is to yourself, to show up, to practice and to hold space for one another in the community.  I agree to connect with my family doctor or mental health therapist for emotional or physical support for any issues arising during the time of the MBSR program *
Required
Limits of Confidentiality: What you discuss during your meditation session is kept confidential. No contents of the sessions, whether verbal or written may be shared with another party without your written consent or the written consent of your legal guardian. *
Required
Audio/ Video Recordings: Meditation classes may involve the audio or video recording of the class for instructor feedback and quality purposes. Neither your name nor any other identifying information will be associated with the recording, and/or the transcript. Only the meditation teacher will be able to listen/view the recordings. By signing this form, I am allowing the meditation teacher to audio/video record me as part of this meditation class. *
Required
Liability Waiver: I hereby agree to the following: 1. I am participating in classes or services during which I will receive information and instruction about meditation. I recognize that I may also choose to do physical movement, such as yoga, sitting, standing and walking meditation. I represent and warrant that I have no physical or mental health condition that would prevent my safe participation in meditation classes. 2. In consideration of being permitted to participate in the meditation classes, I agree to assume full responsibility for any risks, injuries or damages, known and unknown, which I might incur as a result of participating in the program and I knowingly, voluntarily, and expressly waive any claim I may have for injuries or damages that I may sustain as a result of participating in classes or workshops. *
Required
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