MBCT Registration - Mindfulness Center

Course Start Date*

Please enter the start date of the MBCT course for which you are registering.

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Personal Phone*

Work Phone

Preferred Email Address*

Date of Birth*

Occupation

How did you hear about us?*

Newsletter
Family/ Friend/ Colleague/ Co-worker
Web search

What are your expectations and aspirations for taking this class?*

Do you have any experience with meditation?*

Yes
No

If yes, please describe.

Most people choose to take MBCT because they have experienced depression. How would you describe your experience with depression and/or anxiety? Are either of these present currently?*

Many, but by no means all, MBCT participants are or have been in therapy at some point. Are you currently seeing a therapist or counselor?*

Yes
No

If yes, have you talked with your therapist about attending this class?

Yes
No

Have you ever had or been treated for depression, anxiety, bipolar disorder, suicidal thoughts or behavior, PTSD, drug or alcohol addiction, an eating disorder, schizophrenia or other psychosis, or any other psychological condition?

Yes
No

If yes, please specify condition(s) and date(s) below.

Is there anything else that would be helpful for the instructor to know?