Mindfulness-Based Stress Reduction Pre-Course Questionnaire

Mindfulness-Based Stress Reduction

Pre-Course Questionnaire
Thank you for filling out this form. This form serves to let the instructor 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. You may wish to sit in a quite space to fill in this form, which can take up to 20 minutes.
Which MBSR Course will you be attending?*

Fall 2024Spring 2025Other
Have you watched the orientation video?*

YesNo
Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Preferred Pronouns:
What is the primary reason for participating in the MBSR program?*
What is your occupation? If retired or not currently working, please indicate.*
What is your living situation?*

SingleMarriedDivorcedWidowedSeparatedNot married, living with partnerPrefer not to sayOther
Do you have any children? If yes, please list their age(s).*
Would you say that you have close friendships?*

YesNo
Please describe your current quality of sleep.*
Do you currently use illegal substances?*
Do you have a history of illegal substance misuse?*
Are you currently engaged in psychotherapy or counseling?*
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.
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 goals you have for taking the MBSR course.*
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
After I read through the questionnaire, I would like to check in with you over the phone. What is the best phone number to reach you on for the 10-minute consultation call?*
Please enter a valid phone number.
Please select a day and time for us to connect for a 10-minute consultation call.*
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 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 45-60+ minutes per day), as part of the 8-week MBSR program.*

I agree
Should be Empty:

Mindfulness-Based Stress Reduction

Demographic Information