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Mindfulness Based Stress Reduction Program
Assessment of readiness to participate in the 8 week/9 session program
Name
Your answer
Age
Your answer
Contact details - address, email, phone, Skype
Your answer
What is your reason (s) for wanting to participate in this program at this time?
Your answer
What form(s) does stress take for you?
Your answer
What practical ways do you use to manage stress?
Your answer
Which of the following areas are you consistent in? Check all that apply
Use of social media on a daily basis (1 is low and 5 is high)
What are the 2 main positive emotions that you experience regularly?
Your answer
What are the 2 main negative emotions that you experience regularly?
Your answer
Any physical illnesses and/or disabilities; emotional challenges; short or long term diagnosis?
Your answer
Are you on medication?
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