Mindful Eating Maintenance Registration Form

Course Start Date*

Please enter the start date of the Mindful Eating 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 you expectations and aspirations for taking this class?*

Many, but by no means all, Mindful Eating 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 or are you currently being treated for a psychological condition such as depression, eating disorder, drug/alcohol addiction, anxiety disorder, psychosis, schizophrenia, mania or any other psychological condition?*

Yes
No

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

If you have an active eating disorder, please check the "Yes" box below to request an individual conversation with Barbara Maillle, LCSW, to determine if the class is appropriate for you at this time.*

Yes
No

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