Participant Survey

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 MBSRrichmond@gmail.com.

* Indicates required field

Class Session (Season/Year, for example: Winter/2018) *

Name *

First

Last

Email *

Phone *

Occupation *

What brings you to our mindfulness program at this time? *

What are three personal goals you have for the program? *

What are some of your greatest worries? *

What do you care about most or what is one of the things that brings you the most joy? *

Sleep Quality? *

Do you Exercise? If so, about how much? *

Do you eat a balanced diet? *

Caffeinated drinks per day? *

Amount of alcohol per week? *

Do you smoke or vape? *

Do you take prescription medications? If so, please list (optional). *

Any history of substance abuse? Regarding issues of addiction/sobriety, it is recommended you have been in recovery for at least 3 months before taking the class. *

Have you had any surgery or injuries that may interfere with gentle yoga movements? If so, how recently? *

A heightened awareness of emotions can be a natural part of being mindful. For some people this can result in a need or desire for extra psychological support. Are you receiving psychological support at this time? *

Do you experience chronic pain? If so, what is the nature of the pain and how does it tend to affect your life? For example, does it get in the way of doing what you need to do or enjoyment of life? *

How did you hear about this program? For example, website, friend, peer? *

If there is anything else you'd like your instructor to know, or any specific questions you have, you may write them here. *

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.

Informed Consent Agreement *

Agree

Submit

Participant Survey and Consent Form​

Participant Survey and Consent Form