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Mindfulness Based Stress Reduction Intake Form

By filling out this form, you will help me to maximize my effectiveness as your instructor. I hope the experience of this program will be a beneficial one. Upon receiving this form, I will contact you to set up an interview. 

General Information 

Name:  
Date of Birth (MM/DD/YYYY):  
Rice Affiliation:  
Mailing Address:    
Email:  
Phone (Cell):   
Phone (Home):  
Name and Number of Emergency Contact
 
Occupation/Work Status:
 
Relationship Status:  
Number of Children:  
 

Average hours slept at night/Quality of sleep:    
Please indicate any past or present medical conditions or physical injuries:    
Medications:   
What kind of exercise do you manage to do each week/frequency?    
Do you or have you ever meditated?

  

Do you or have you ever practiced yoga?      
Do you smoke? If yes, how many cigarettes a day?    
Alcohol/recreational drug use/frequency:  
History of depression or anxiety:    
Are you currently undergoing therapy for mental health reasons? If yes, please explain.     
Were you referred to this course by a doctor or clinician? If yes, who?   
What is the main reason you are participating in a stress reduction course?    
What do you care most about in your life?    
What are your greatest worries or stressors?    
Is there anything else you would like for me to know about you?