Mindfulness Based Stress Reduction Intake Form

Preferred name (if different from above)

Pronoun

Phone*

Email*

Emergency Contact Phone*

Date of Birth*

Cancer diagnosis*

Do you have any previous experience with Meditation? (including any mindfulness program attended at InspireHealth):

Do you have any previous experience with Mindful movement? (e.g. yoga, etc.):

What is the main reason for participating in the MBSR course? What do you hope to get out of it?

MBSR is an eight-week course with additional home practice between sessions. Do you see any barriers to attending class regularly or to doing the home practice?

Please specify:

Is there anything you would like to share about your mental health and Well-Being (e.g. diagnoses, medications, depression and/or anxiety, experiences of suicidal ideation or attempts, etc.)?

What are your current stressors? How do you currently cope with stress?

Is there anything else that you would like the instructors to know? Do you have any questions?

*This program will be happening online via Zoom. Participation will require stable internet and a device with access to video and audio. A cellphone is not recommended as a device for group programming due to limited screen space for engaging with the larger group. Also, to protect the privacy of all participants, we request that each person join from a private space where the videos and voices of other participants will not be seen by others in the household.

* Please note that completing this form does NOT guarantee you a spot. There are limited spaces and we will contact you to confirm registration and waitlist.

Mindfulness Based Stress Reduction (MBSR) Intake Form

Mindfulness Based Stress Reduction (MBSR) Intake Form