MBSR Online Intake: Linscott Spring 2020
This form is necessary to complete prior to taking the MBSR (Mindfulness-Based Stress Reduction) program. All responses are confidential and read only by your MBSR teacher, to help them best support you while you participate in the program.
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Email *
Today's Date *
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Day and Time of Class You are Taking *
Participant Information
Your Name (First and Last) *
Email Address *
Full Mailing Address (please include zip/postal code) *
Best Phone Number (please include country and area code) *
Emergency Contact - Name
Emergency Contact - Phone Number
Gender & Pronoun Use
At Brown Mindfulness Center, we uphold the values of the entire university in being inclusive and respectful to all people, including LGBTQ persons. (Only answer if you feel comfortable.)
I use these pronouns (for example: she, her and hers; he, him and his; they and theirs, or other
How did you hear about this program?
Why are you choosing to take this class at this time?
What are three ways you hope to benefit from this class? *
Do you have children? If yes, how many and what are their ages? *
Health and Well Being
Having a general understanding of current health issues and past health history and significant life events can help us know how to best support you in participating in the MBSR class.
Please list any previous significant injuries, physical and behavioral health conditions and overnight hospitalizations for medical, surgical or psychological conditions (include year, where applicable), that may impact your experience of or participation in the class. *
What do you currently do to take care of yourself? *
When you are feeling stressed, or overwhelmed, what do you normally do?
Briefly describe any current or previous experience with meditation or yoga.
What do you care most about in life?
What supports your well-being? What gives you the most pleasure in your life?
What are you most worried about?
Briefly describe any current or previous experience you have with meditation and/or yoga? *
What do you care most about in life? *
Is there anything else you would like to share or that you think is important that we know so we can best support you in participating in this class? *
Optional
The following questions are optional. Answering these questions may be helpful in how best to support you in relation to the meditation practices learned in the MBSR group.
Have you experienced any major averse, traumatic or extremely stressful life events?
Clear selection
Are you aware of any current symptoms or behaviors as a result of the experience(s)?
Clear selection
How have you supported yourself in healing (i.e. therapy, counselling, education, medication or other means)?
Are you currently engaged with or have you, in the past, sought counseling, therapy, psychotherapy, or psychiatric care?
Informed Consent
The MBSR orientation includes an introduction to the program components and an explanation of program risks and benefits. If you have not yet attended an orientation, you must return to this question and select "agree" before attending class.
By checking the box below, I indicate that the risks, benefits and possible side effects of the 8-week Mindfulness-Based Stress reduction program have been explained to me.  I understand that the components of the program include skill training in a variety of mindfulness meditation modalities and mindful movements, for which I’m responsible, as needed, to modify or adapt, with the support of my instructor.  It is also my understanding that if, for any reason, I am unable to, or think it is unwise for me to engage in these practices and exercises either during class or in home practice, that I am under no obligation to engage with these skills, nor will I hold the Mindfulness Center at Brown University responsible for any injury or incapacity incurred from the practices or movements.  Finally, I understand and agree to the commitment to attend the 8-weekly sessions, the all-day class, and complete the home practice assignments (of 45-60+ minutes per day), as part of the 8-week MBSR program. *
Required
Thank you.
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