8 Week MBSR Course Application - Mindful Living In San Luis Obispo

Introduction

Thank you for filling out this form. Please be assured that due to the personal nature of the questions your information will be kept in strict confidence. The Mindfulness-Based Stress Reduction (MBSR) program taught by Laura Liss is an educational course in a group setting, not group therapy, psychological treatment, or medical treatment. MBSR can be helpful to many individuals with a wide variety of concerns. However, certain factors can interfere with a participant’s success. It is your responsibility to inform me, before class begins, of any limitations or issues, physical or psychological, which could affect or be affected by the practice of meditation or yoga. Please discuss individually with me if any of the following issues apply: physical limitations, severe anger or depression, suicidal thoughts, history of psychological trauma, serious psychological condition, serious medical condition, previous psychiatric hospitalization, substance abuse/dependency, or excessive use of alcohol and/or recreational drugs.

Please select an option *

Fill out this form and submit online
Answer these questions during a phone call with Laura. If you choose this option please email Laura at lauraliss@verizon.net with your name, address and phone number and she will contact you to schedule a phone call.

Name *

First

Last

Age *

Address *

Email *

Email

Confirm Email

Phone Number *

Do you have any experience with meditation? If yes, please describe. Also, share whether you have experienced anything unusual while meditating. *

Have you participated in any mindfulness or MBSR courses? *

Yes
No

If yes, what course(s) with whom and when? *

Why are you interested in taking this class? *

Are you currently experiencing physical pain? If yes, please describe. Are you under the care of a doctor for this? *

Do you have trouble sleeping? Do you take any medication for this? *

Do you suffer from depression, anxiety or post-traumatic stress? If yes, please explain whether the problem is chronic, whether you feel you are currently experiencing the problem and what you are doing to cope. *

Have you ever received treatment for a mental health concern(s)? *

Yes
No

If yes, please describe how your mental health may impact your experience in the class. *

Are you currently seeing a therapist? *

Yes
No

Have you ever been hospitalized for psychiatric reasons? If yes, when? *

Are you currently taking any psychiatric medication? If yes, please describe. Is this prescribed by your primary doctor or are you currently under the care of a psychiatrist? *

Do you currently use drugs or alcohol? How much? Have you ever been in treatment? If yes, please explain. *

Please check all of the following that apply to you: *

Please expand on anything related to the list above or describe any current physical conditions or limitations that may impact your experience of participating in the movement practices of the class. *

Is there anything else you would like me to know? *

How did you learn about this course offering? *

Please check your schedule and confirm that the dates of the MBSR course, including the Day of Mindfulness, will work for you. *

Yes, the schedule works for me
Send an email to Laura at lauraliss@verizon.net and let her know which dates will not work for you

Does the fee for the course present an obstacle for being able to attend *

I am able to afford the fee
I am unable to afford the fee and will contact Laura at lauraliss@verizon.net to discuss this further

Thank you for taking the time to fill out this form. Please sign (type) your name in the space below to act as your signature and you will receive an email confirmation from the instructor, Laura Liss. (copy) *