Application Form: Group Leader Training (Mindfulness Training for Primary Care)
Thank you for filling out this application form! After you have filled out this form, a member of the CMC staff will get back to you by Feb 1 about any questions, and with a registration link. You may get in touch with us anytime at cmc@challiance.org or 617-591-6132. Thank you!
What is your name?
Your answer
What is your e-mail address?
Your answer
What is a good phone number to reach you at?
Your answer
Please describe yourself in a couple sentences.
Your answer
What is calling you to attend this training? (3-5 sentences)
Your answer
What is your mindfulness / meditation experience? Please describe as it feels appropriate to you. Please also include types of practice, app or website use, years of practice, any experience taking an 8-week mindfulness intervention, any retreat experience, and average daily practice type and time.
Your answer
What is your current occupation?
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What is your age?
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How do you identify your race?
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How do you identify your ethnicity?
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How do you identify your gender?
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Are you a CHA staff member? If so, what is your role at CHA?
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Are you interested in leading MTPC as a clinical intervention (and plan to bill these groups to insurance)? If so, what is your current employer and what clinical training/license do you have?
Your answer
If you are interested in leading MTPC as a clinical intervention, are you able to commit to co-leading two groups at your site with weekly videoconference supervision with CMC staff during the groups? If there are any barriers or difficulties that you foresee, please describe briefly here.
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Have you completed an 8-week MBSR course as a participant? If so, where, and who were your teacher(s)?
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How many sessions of the 8 weekly MBSR sessions did you attend?
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Did you attend the MBSR all-day retreat?
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Are you able to commit to 6 months of daily practice following the Group Leader training?
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Have you had any experience leading mindfulness or mind-body interventions before?
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Have you had any experience leading groups in clinical settings before?
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Are you interested in the training with an intention to lead in OBOT (Office-Based Buprenorphine Treatment) settings?
Please tell us how your taking this training may impact your community/healthcare system
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Please describe your specific aspirations for making mindfulness accessible to vulnerable populations
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What are your hesitations or fears about attending this group leader training?
Your answer
Are you applying for a scholarship to attend this training? (apply at www.chacmc.org/scholarship)
Thank you for filling out this application! You will be contacted by a member of our staff with any follow-up questions, and the link for registration. Anything you'd like to add here?
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