Institute for Integrative Mindfulness and Movement: MBSR Feedback Form
Thank you for your interest in the MBSR Program. Tell us a little bit about yourself and your interest so we can be in touch with additional information about the program and let you know when we are offering the program.
* Required
First Name
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Your answer
Last Name
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Your answer
Email Address
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Your answer
Phone Number (Optional)
Your answer
Why might you be interested in taking the MBSR Program?
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To better cope with stress
To better cope with anxiety
To better cope with pain
To better cope with chronic condition / health issues / illness
To better cope with life challenges
To learn mindfulness based practices
Other. Please provide details in the Sharing Box at the bottom of the page.
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What would be your preferred day(s) to take the course? Please tick all the options that work for you.
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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What would be your preferred time(s) to take the course? Please tick all the options that you like.
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6:30am
7am
7:30am
8am
8:30am
9am
9:30am
10am
10:30am
11am
11:30am
12pm
12:30pm
1pm
1:30pm
2pm
2:30pm
3pm
3:30pm
4pm
4:30pm
5pm
5:30pm
6pm
6:30pm
7pm
7:30pm
8pm
8:30pm
9pm
10pm
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Sharing Box. Please use this space for any question, comment, feedback, suggestion or anything you'd like to share. Thank you.
Your answer
Does your workplace offer a wellness program or event(s) for the employees from time to time? If so, feel free to leave the email of the person we could contact to offer services within your organization. Thank you.
Your answer
Thank you for your feedback. Feel free to save our contact information for reference. We offer classes to organizations, groups and individuals. May you spread well-being and continue to live and inspire healthy active lifestyles all around you! | The Institute for Integrative Mindfulness and Movement | Website: https://integrativemindfulnessmovement.com | Email: info@imminstitute.com
#letspreadwellbeing and #livehealthyactivelifestyles
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