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MBSR Registration Questionnaire
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Your name
Your answer
Email address
Your answer
Phone Number
Your answer
What is your main reason for participating in the MBSR Program?
Your answer
What is your occupation?
Your answer
Date of Birth
MM
/
DD
/
YYYY
Please describe the quality of your sleep.
Your answer
Do you have a history of substance abuse? Please describe.
Your answer
Do you take prescription medications? Please list.
Your answer
Are you currently engaged in psychotherapy? Please describe.
Your answer
During the last month have YOU:
Considered suicide
Sought psychiatric help
Had thoughts of death or dying
Had urges to beat, injure, or harm someone
Had urgres to smash or break things
Had spells of terror or panic
What do you care about most?
Your answer
What gives you the most pleasure in your life?
Your answer
What are your greatest worries?
Your answer
How did you learn about this program?
Your answer
Anything else you would like us to know?
Your answer
We take payment through Venmo, CashApp, or credit card (adds a fee). Which one will work for you?
Your answer
We are offering this class at a sliding scale of $50-$350. How much will you be paying?
Your answer
Thank you. We will be in touch soon.
Your answer
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