Individual Mindfulness Registration Form – 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 sessions with Laura Liss are based on MBSR and are educational - not therapy, psychological treatment, or medical treatment. The sessions can be helpful for people with a wide variety of concerns. However, certain factors can interfere with a participant’s success. It is your responsibility to inform me 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 fill out and submit the form up until and including your phone number.

Name

First

Last

Age

Address

Email

Confirm Email

Phone Number

Are you interested in individual, couple or group sessions?

What would you like to explore in mindfulness sessions?

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

Are you currently experiencing physical pain in your body? 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 mental health concerns?

Yes
No

If yes, please describe and also share any information you think it would be helpful for me to know, especially ways your current or past mental health may impact your experience with mindfulness.

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.

Is there anything else you would like me to know?

Please check all of the following that apply to you:

Please expand on anything related to the list above including conditions or limitations that may impact your experience of participating in mindful practices.

How did you find out about mindfulness sessions with Laura Liss?

Internet search
Flyer about MBSR courses
Recommendation of friend or family member
Recommendation of therapist

If recommended by a therapist, please include their name here:

Thank you for taking the time to fill out this form. Please type your name below to act as your signature and Laura Liss will contact you about scheduling a session. Please call 805-458-4002 if you do not receive an email or phone call from Laura.