Mindfulness-Based Stress Reduction (MBSR)  Participant Questionnaire and Goals

Welcome to the Mindfulness Based Stress Reduction (MBSR) Informational Orientation and Course.

Please complete this questionnaire so we may better get to know you, your personal needs in this program, and how you see your wellbeing. The following questions are personal in nature, so know that this form is voluntary, questions are optional and kept confidential.

You and the course instructor are the only people who will see your responses. 

Throughout this questionnaire, we invite you to reflect on the circumstances that have led to your participation in MBSR. The information that you provide will aid your instructor in preparing and better understanding the stress and challenges that members of this class are facing, so that she/he can fully support participants on their path to developing coping skills through mindfulness. 

This next section is about you!

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* 1. Contact preferences during the course and experience ?

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* 2. What is your primary reason for taking the course? Select all that apply.

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* 3. Please rate your overall stress level at this time

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* 4. Most people are ready to take the course. Yet, it is important to consider whether the course is right for you at this time. This is why we have this questionnaire and the informational orientation to get a feel for the course and clarify expectations.

Persons with a history of the following concerns may have difficulty with this course. If these issues pertain to you, please talk to your course teacher prior to starting the classes to determine if you have enough support and this course is right for you at this time.

Please check the most important current medical issues that may be helpful for your instructor to know about (for example chronic pain, depression, anxiety and so on). Add additional concerns in the comment box. 

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* 5. Comments 

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* 6. Please describe your support system (for example, a counselor, therapist friend, family, life coach, pets and so on).

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* 7. While many consider the MBSR course as therapeutic, and yet it is not therapy. If you are also under the care of a medical provider or psychotherapist, please confirm that you will work with them if any health concerns or if anything comes up from your MBSR/mindfulness practice, and that you will be sharing with them for their support.

I confirm that I will discuss with my medical or mental health provider any troubling concerns or material that arises for me from the MBSR course.

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* 8. If you have questions or concerns about the online format, or any of the movements practices (easy hatha yoga, Qigong, stretching) please describe those here.

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* 9. If you know that you will miss 2 or more classes and/or the all-day retreat class, please pause now and email mindfulness@hcmed.org. Participating in an orientation is required.

Barring an emergency, will you be attending the informational orientation, at least 7 out of the 8 weekly classes, and the all-day class retreat? Yes/No

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* 10. Thank you for answering all questions as honestly as possible, keeping in mind that as life circumstances are constantly changing, your responses are not seen as the “final word” but as a reflection of where you are in this moment and at this time in your life.

At the end of this 8-week program, you may use this questionnaire as an opportunity to reflect upon changes that you have made throughout the course. and a reflective evaluation. We will also provide you with resources for how you can use the mindful techniques you’ve learned in the class to continue to adaptively manage stress, life challenges and grow in your mindfulness practice.

Please list 2 - 3 outcomes you would like to have for taking the MBSR program, in order of preference.

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* 11. Online signature and agreement for video recording classes.

Feel free to call 612-873-8048 with any questions. 

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