Registration Form for NJ Center for Mindful Awareness--MBSR Course in Lakewood
Welcome and Congratulations for your interest in cultivating greater mindful awareness in your life.
Please know that the information you share here will be treated with confidence and respect.
In addition to some of the basics, it will be helpful to know a bit about your intentions, health and any physical or emotional challenges you may be facing.

Please know that for any question you can make a note that you would prefer to contact us directly with this answer (this will satisfy the reguired response on the form ).

We make a strong effort to have a short phone conversation with all potential students anyway so anything that feels to personal for an online form like this can be deferred for that phone call.
Looking forward to talking soon. with warm regards, Ken and Maria
Full Name *
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Street Address
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Phone # *
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email address *
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emergency contact *
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How did you find out about the Programs offered by the NJ Center for Mindful Awareness
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Which course are you interested in ? *
Season and Location i.e Winter Course in Lakewood, Spring Course in Highland Park
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What is your primary reason for taking the MBSR Course? *
Your answer
Do you struggle with any chronic pain issues? *
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Any other physical health challenges that might be important with regard to your participating in the course? *
Your answer
Any emotional/psychological challenges that might be important with regard to your participating in the course? *
Your answer
Are you currently taking any prescription medications? If so, please list. *
Your answer
Do you have any prior experience with mindfulness practices or have read books about mindfulness?
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Are you aware that participating in the course will also involve devoting time to daily mindfulness practice?
Please know that we want to support your motivation to engage in this process of cultivating greater self-awareness and self-compassion in your life. Is there any reason why this might be a challenging time for you to take this course? *
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We look forward to talking with you about the upcoming course. Can you please list any preferred days/times when you can be reached by phone. *
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