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Mindfulness & Meditation
Mindfulness & Meditation
MBSR program
One-on-one Mindfulness Session
15 Minute Mindfulness Call
Mindfulness Retreat
Mindfulness Meditation Hour
WorkLife Mindfulness
Personal Mindfulness
Contact
Pre-Program Survey
Thank you for taking the time to fill out this form. All information you include and share in this form is confidential.
Contact Lisa
with any questions.
*
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
W Virginia
Wisconsin
Wyoming
Age
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<20
20-29
30-39
40-49
50-59
60-69
70-79
80-89
90+
Preferred Prounouns and/or Preferred Title
Family responsibilities and role, both immediate and extended
Do you have a support system that you connect with regularly?
Describe your sleep quality
How many caffeinated drinks do you have a day and what type are you drinking?
Describe the type of food you generally eat
Describe your exercise habits
Describe your use of drugs and/or alcohol and frequency of use
Are you currently in counseling or therapy?
Yes
No
Have you received treatment for mental health issues?
Yes (please describe below)
No
If yes, please describe
Describe current medical and health issues and status
How do these health issues affect your life?
Do you experience any chronic pain? If yes, please describe.
Do you experience any of the below signs of stress. Please mark all that apply.
Addictive behavior
Anger
Anxiety
Appetite changes
Breathing issues
Concentration problems
Decreased drive
Depression
Detachment
Doubt
Emotional outbursts
Exhaustion
Fear
Feeling on edge
Frequent accidents
Frustration
Guilt
Headaches
Irritability
Lethargy
Loss of enthusiasm
Muscle tension
Negativity
Numbness
Panic
Sadness
Sleep disturbances
Worry
What do you do to manage stress?
Advocating
Art or crafting
Cleaning
Entertainment
Humor
Journaling
Leaning on your network of friends and family
Meditation
Objectivity
Physical activity
Reading
Reorganizing
Seeking support
Self-reflection
Setting limits and boundaries
Sharing and communicating
Sleep
Spirituality
Writing
Yoga or pilates
What is your experience with meditation and mindfulness?
What do you do for fun? What are your hobbies? How do you fill your free time?
What is most important to you?
What worries you?
What gives you pleasure in your life?
What are your MBSR goals?
What would you like to add that you think may be helpful as you move forward in this MBSR course?
Sumbit Form