MBCT Teacher Training: Participant Background Form

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Thank you for registering for the MBCT Teacher Training Program, which will take place at the CHA Center for Mindfulness and Compassion on Thursday September 26, Friday September 27, Saturday September 28 and Sunday September 29, 2019.

As a requirement for enrolling in this the training, we ask that all participants complete the below form upon registration and read the 2nd edition of the Mindfulness-Based Cognitive Therapy for Depression book by Zindel Segal, J. Mark Williams and John Teasdale.

Contact us with any questions at the CHA Center for Mindfulness & Compassion: 617-591-6132 or cmc@challiance.org

Name *

Email *

State and Country of Residence *

Education Degree (field/discipline) *

Do you have a regular meditation practice? (50 words or less for each question) *

Please state the tradition of your meditation practice: *

Typical length of each practice session: *

Number of years you have been practicing *

Please list any teacher-led silent meditation retreats you’ve been on: (Date, Location, Teacher Name) *

Do you have a mindful movement practice (yoga, tai chi, qi gong): (50 words or less) *

Please state why you want to take this MBCT teacher training in 250 words or less: *

Dietary restrictions *

None

Vegetarian

Vegan

Kosher

Gluten-free

Other:

Which racial and ethnic categories do you use to identify yourself? (Check all that apply)

Black, Haitian or African American

Asian, Indian

Native American Indian or Alaskan Native

Native Hawaiian or Pacific Islander

Hispanic/Latinx

White, Caucasian

Prefer not to answer

Identify using other categorization

How do you self-identify your gender?

Female

Male

Genderqueer or not exclusively male or female

Don't know

Prefer not to answer

Other

Clear selection

What is your Marital Status?

Single

Married or living with a partner

Divorced

Widowed

Clear selection

How do you identify your sexual orientation?

Lesbian, gay or homosexual

Straight, or heterosexual

Bisexual

Something else

Don't know

Prefer not to answer

Clear selection

Please share what you consider your primary language:

English

Portuguese

Haitian Creole

Spanish

Bengali

Other

Clear selection

Is English your first language?

Yes

Clear selection

Employment Status:

Working full-time

Working part-time

Retired

Disability (SSDI)

Unemployed, not disabled

Stay-at-home parent or spouse

Other

Clear selection

Are you a CHA employee?

Yes

Clear selection

Are you a CHA patient?

Yes

Clear selection

Years of Education Experience:

1-8: Grade School

9 - 12: High School

13-16 College/University

16 + Graduate

Clear selection

Thank you for completing this Background Form!

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