Mindfulness-Based Stress Reduction
Registration Form

By completing this questionnaire you will enable me to maximize my effectiveness as your instructor. Your answers help me to understand the context of the stress in your life and the solutions you are seeking. Your answers will be kept strictly confidential and are only for my knowledge and understanding to support you during the course.

I will follow-up with you by email to schedule a phone consultation to clarify any questions I may have after receiving your submission.

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At the end of the course, all participants who have attended will receive a certificate for their participation.

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I understand that:

  • The information above is for the use of the MBSR instructor to tailor this group to my skills and abilities.

  • MBSR is not designed as a medical treatment and does not replace medical treatments by licensed health care providers.

  • To receive the full benefit of the MBSR experience requires regular class attendance and regular at-home practice.  Finding time for these activities may require a re-ordering of priorities during the duration of the course.

  • Once the course has begun in session #1, refunds will not be provided. However, if by class #2, you find there is a conflict with your schedule, we will hold your registration fee for a future course date. After class #2 no refunds or holdovers will occur.

By submitted this form, you are agreeing to your understanding of these statements.

Thank you for taking the time to answer these questions. If you have any questions or concerns about this questionnaire, let's talk about it. I will be following up with you for a phone consultation shortly.

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Tel: (480) 861-6062

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