WFL MBSR Application

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Thank you for your interest in the 8 week Mindfulness Based Stress Reduction (MBSR) course. Please fill out this confidential application. Please note: If you had or have experienced: psychological hospitalizations, thoughts of hurting self/other, excessive thoughts of death/dying, terror/ intense panic, this course is not suggested. Please contact your healthcare provider for assistance.

Email *

Dr. Jon Kabat-Zinn founded the Stress Reduction Program in 1979. Since its inception, more than 25,000 people have completed an eight-week Mindfulness-Based Stress Reduction Program (MBSR) and learned how to use their innate resources and abilities to respond more effectively to stress, pain, and illness. The central focus of the course is intensive training in mindfulness meditation and its integration into the challenges and adventures of everyday life. *For more information about Mindfulness and MBSR, please visit https://www.umassmemorialhealthcare.org/umass-memorial-medical-center/services-treatments/center-for-mindfulness/faqs *

I understand

What is the course structure & commitment? Eight weekly classes, 2 ½ hrs each (31 hours of direct instruction) // One retreat on a Friday or Saturday // Daily home practice assignments for 45-60 minutes each day // You must be willing to make a strong commitment to attend all classes and to practice daily home assignments for eight weeks. *

I understand

First and last name & contact phone number *

DOB *

YYYY

Occupation and location *

What are your reasons for participating in the MBSR Program? (check all that apply) *

Stress Reduction

Improve quality of life

Become more Mindful

Reduce anxiety

Improve a physical health problem

Improve concentration and focus

Improve sleep

Adjust to life changes

Cope with pain

Other:

Required

For the next 4 questions, please use the 1 to 5 rating scale. Sleep Quality 1 -5. *

Poor

Excellent

Level of Stress *

Poor

Excellent

Level of Joy *

Poor

Excellent

Satisfaction with Life *

Poor

Excellent

In daily life, what do you care about most? *

What gives you the most pleasure in life? *

What are your greatest worries? *

Is there anything else that you would like to share with me? Any questions? Wonders? or Concerns?

A copy of your responses will be emailed to the address you provided.

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