MBSR PROGRAMS IN RICHMOND, VA
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    Participant Survey and Consent Form
    ​

    Mindfulness Program Enrollment Form

    This is confidential information collected for all program participants. This information is used solely to provide your instructors with an overall picture of your health as it relates to stress and participation in the class. The information provided here will help your instructors tailor the program to meet everyone's needs. 

    ​You are always welcome to discuss any concerns (about this form or anything else related to class) with Chelsea or Victor at 703-973-3473, or [email protected].
    first, last
    Please put some thought into your response -- your goals can help support you in how you participate in the class.
    e.g., terrible, poor, fair, good, excellent
    Many medications are specifically tied to conditions that are influenced by stress. Some examples: chronic pain, blood pressure, immune health, allergies, depression, anxiety, blood sugar, cholesterol, brain health, digestive health (i.e., ulcerative colitis, IBD,) migraines, seizures, and numerous others.

    ​​I AGREE TO THE FOLLOWING TERMS OF SERVICE: This mindfulness training program includes skill training in relaxation and meditation methods as well as gentle stretching (yoga) exercises. There will be in-class practice as well as home practice using recordings. I understand that if for any reason I am unable to or think it unwise to engage in these exercises either during the weekly sessions or at home, I am under no obligation to engage in them or participate, nor will I hold the above liable for an injury incurred from these exercises. Furthermore, I understand that I am expected to attend each of the eight weekly sessions, the day-long session, and to practice the home assignments during the duration of the training program, or to talk to the instructor about special needs related to the schedule or participation concerns.
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