Today’s Date: Course Date/Time:
Your name Your email Phone
Your Website URL (required)
Mailing Address
Emergency Contact
Emergency Phone Number
Do you have children, If yes, how many and what are their ages?
Gender & Pronoun Use (Answer if you feel comfortable)
Inclusivity and respect for all people is a fundamental part of VT Mindfulness. 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?
Briefly describe any current or previous experiences with meditation and/or yoga.
Why are you choosing to take this class at this time?
What are three ways you hope to benefit from this class?
Having a general understanding of your past health history, current health issues, significant life events can help me know how to best support you when participating in the MBSR class.
Where appropriate, 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.
How do you currently take care of yourself?
When you feel stressed or overwhelmed, what do you normally do?
What gives you the most pleasure in your life?
What are you most worried about?
What do you care most about in life?
Is there anything else you would like to share or that you think is important for me to know in order to best support your participation in this class?
The following questions are optional. Answering these questions may be helpful to supporting your participation in the meditation practices learned in this MBSR class.
Have you experienced any major adverse, traumatic or extremely stressful life events? YesNoI prefer not to discloseI prefer to discuss individually with teacher
Are you aware of any current symptoms or behaviors as a result of the experience/s? YesNoI prefer not to discloseI prefer to discuss individually with teacher
How have you supported yourself in healing (i.e. therapy, counseling, education, meditation or other means)?
Are you currently engaged with or have you, in the past, sought counseling, therapy, or psychiatric care? YesNoCurrentlyI prefer not to discloseI prefer to discuss individually with teacher
