Mindfulness Based Stress Reduction Intake Form

Name*

First Last

Preferred name (if different from above)

Pronoun

Phone*

Email*

Emergency Contact*

Full Name Relationship

Emergency Contact Phone*

Date of Birth*

Cancer diagnosis*

What is your current phase of diagnosis?*

Newly diagnosed

In-treatment

Post-treatment

What treatment are you currently receiving? (check all that apply)*

Surgery

Chemotherapy

Radiation therapy

Immunotherapy

Other

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?

This course involves mindful movement like gentle yoga, do you have any physical limitations that would be helpful for us to know about?

Yes

Please specify:

Are you currently engaged in psychotherapy (e.g. counselling, group classes, psychiatry, spiritual counselling, etc.)?

Yes

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.

Consent to group services and telemedicine:

Multidisciplinary communication: InspireHealth’s multidisciplinary team works as one unit of confidentiality and care, ensuring that any collaboration and communication is done with the utmost respect and ethical consideration.
For the purposes of providing this course, this screening form and other information deemed relevant and necessary will be shared with the contracted facilitator through a secure form of communication.

Confidentiality is an essential part of InspireHealth’s practice. Your privacy is important to us. Your healthcare information belongs to you and is held in confidence by InspireHealth, with the exception of the following circumstances:

1. If the information is required by law to be disclosed (e.g., a child or vulnerable person may need protection, the information is subpoenaed, or court ordered to be released).
2. If staff believe there may be a significant risk of harm to you or to others.
3. When informed and voluntary consent is provided by you to release information.

Patient records: Attendance will be tracked and documented in a secure electronic medical records system, which is encrypted and only accessible by InspireHealth clinical staff. Email communication will be used for program communication and coordination, please note that email content may become part of your InspireHealth chart.

Telemedicine: InspireHealth offers the option to access individual and group services through telemedicine, which is the use of telephone and/or video conference platforms. Participation in telemedicine is completely voluntary. At any point, you can choose not to access telemedicine services and speak with an InspireHealth staff member about alternative options for receiving support. If you choose to utilize telemedicine services, InspireHealth will not take video and/or audio recordings of the session. Video calls will be hosted through TELUS Business Connect and Zoom, which are both PIPEDA and PHIPA compliant. For TELUS Business Connect’s privacy policy visit: www.telus.com/privacy. For Zoom's privacy policy visit: https://zoom.us/privacy/. When participating in individual or group services through telemedicine, InspireHealth clinicians assure they connect from a secure and private setting. Confidentiality may be limited on the end of the participant(s). It is each participant’s responsibility to assure they are in a private and secure setting. As InspireHealth cannot assure the environment of participants, we cannot take responsibility for confidentiality being upheld by participant(s).

Mindfulness Based Stress Reduction Intake Form

Mindfulness Based Stress Reduction (MBSR) 2024 Intake Form