Mindfulness-Based Stress Reduction Pre-Course Questionnaire

Mindfulness-Based Stress Reduction

Pre-Course Intake Questionnaire
Thank you for filling out this form. This form serves to me know a little bit about your background as well as your intentions/goals before starting course. We realize the personal nature of these questions and therefore we ensure your responses will never be shared. The forms will be kept in strict confidence and in compliance with HIPAA laws. No record shall be kept after the course is over.

You may wish to sit in a quite space to fill in this form, which can take up to 20 minutes.

After I read your questionnaire, I will email you directly to schedule a 15-minute VIDEO meeting.
Which MBSR Course will you be attending?*

Fall 2025Spring 2026Other
Have you watched the orientation video?*

YesNo
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Phone Number where I can reach you or leave a message in case of class changes.*
Please enter a valid phone number.
Preferred Pronouns:
What is the primary reason for participating in the MBSR program?*
Where did you hear about the MBSR course?*
What is your occupation or profession? If retired or not currently working, please indicate.*
What is your living situation or relationship status?*

SingleMarriedDivorcedWidowedSeparatedNot married, living with partnerPrefer not to sayOther
Do you have any children? If yes, please list their age(s).*
Please indicate current significant medical problems/concerns.*
Are you currently engaged in psychotherapy or counseling?*
If you are currently engaged in psychotherapy or counseling, please briefly describe your condition and anything you feel is relevant for me to know in order to be attuned to your situation.*
Have you been diagnosed with Post-Traumatic Stress Disorder (PTSD?)*
Would you say you have close friendships?*
Please describe your current quality of sleep.*
Do you currently use illegal substances?*
Do you have a history of illegal substance misuse?*
During the past two months, have you:*

Seriously considered suicide?Sought emergency psychiatric help?Had persistent thoughts of death or dying?Had urges to beat, injure, or harm someone?Had urges to smash or break things?Had spells of terror or panic?None of the above.
Do you have prior experience with meditation? If so, please briefly describe.*
Do you have prior experience with yoga? If so, please briefly describe.*
Please take a moment as you respond to the following three questions:
What do you care about most?*
What gives you the most pleasure in your life?*
What are your greatest worries?*
Please share three (3) personal reasons you have for taking the MBSR course.*
What do you hope get out of the course?*
Is there anything else you would like me to know?*
Demographic Information
Please specify your gender*

FemaleMalePrefer not to sayOther
Which race or ethnicity best describes you? (Please choose only one.)*

American Indian or Alaskan NativeAsia/Pacific IslanderBlack or African AmericanHispanicWhite/CaucasianMutiple EthnicityPrefer not to sayOther
Please specify your age*

18 - 2930 - 3940 - 4950 - 5960 - 6970 - 7980 - 89Prefer not to sayOther
Zip Code
Informed Consent: By checking the box below, I indicate that the risks, benefits and possible side effects of the 8-week program have been explained to me. I understand that the components of the program include skill training in a variety of mindfulness meditation modalities and mindful movements, for which I’m responsible, as needed, to modify or adapt, with the support of my instructor. It is also my understanding that if, for any reason, I am unable to, or think it is unwise for me to engage in these practices and exercises either during class or in home practice, that I am under no obligation to engage with these skills, nor will I hold the Marion Institute, Inc., Sangha New Bedford, LLC, or the program instructor responsible for any injury or incapacity incurred from the practices or movements. Finally, I understand and agree to the commitment to attend the 8-weekly sessions, the all-day class, and complete the home practice assignments (of 45+ minutes per day), as part of the 8-week MBSR program.*

I agree
Should be Empty:

Mindfulness-Based Stress Reduction

Demographic Information