Mindfulness-Based Stress Reduction program

Pre-program form

Thank you for taking the time to fill out this form. All information you include and share in this form is confidential.

Contact Lisa Patterson Raterman (lisa@workingmindfulness.com) with any questions.

Contact Info
Name *
Name
Phone *
Phone
Date of Birth
Date of Birth
How many children do you have? What are their ages? Describe their general health
Are you currently in counseling or therapy?
Have you received treatment for mental health issues?
Do you experience any of the below signs of stress. Please mark all that apply.
What do you do to manage stress?