NEXT STEP:

Please, fill out this intake questionnaire. All information will be kept confidential.

MBSR Orientation Questionnaire

"*" indicates required fields

CENTER FOR MINDFULNESS IN MEDICINE, HEALTH CARE, & SOCIETY™

MINDFULNESS-BASED STRESS REDUCTION PROGRAM

Created by:

UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL
Division of Preventive & Behavioral Medicine

Thank you, for filling out these forms. We realize the personal nature of these questions. Please be assured that the completed forms are kept in strict confidence.

Today's Date

MM slash DD slash YYYY

Name

First Last

Email*

Home Telephone*

Work Telephone

Cell Telephone*

Please indicate which phone number should be used to leave a message.

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How did you hear about the program?*

If it was from a health professional, could you offer the name and telephone number?”

What is your main reason for participating in the Stress Reductions Program?*

What is your occupation?*

What is your date of birth?*

MM slash DD slash YYYY

Family Information*

Please choose one.

Single

Married

Not Married

Living with Partner

Separated

Divorced

Widowed

Do you have children?*

Yes

How Many Children?

What are the ages of your children?

Do you have close friends?*

Yes

Sleep Quality*

Do you smoke?*

Yes

Caffeinated drinks per day:*

Do you exercise?*

Yes

How often?

Do you use drugs or alcohol?*

Yes

How much?

Do you have a history of substance abuse?*

Do you take prescription medications?

(If possible, please list)

Are you engaged in Psychotherapy?

If no, have you been in therapy during the last three years?

Previous overnight hospitalizations? – Medical/Surgical

Please inform the year

Previous overnight hospitalizations? – Psychological

Please inform the year

During the last MONTH have you:

Considered suicide?*

Yes

Sought psychiatric help?*

Yes

Had thoughts of death or dying?*

Yes

Had urges to beat, injure or harm someone?*

Yes

Had urges to smash or break things?*

Yes

Had spells of terror or panic?*

Yes

Please take a moment as you respond to the following three questions.

1. What Do you care about the most?*

2. What gives you the most pleasure in your life?*

3. What are your greatest worries?*

Any additional information you would like to provide to Irena and Rossana, your MBSR instructors? Things such as special arrangements for class, personal present struggles, or any other information you feel like sharing.*

Please, indicate a person we could contact in case of an emergency:*

First Last

How is this person related to you?*

Their phone number:*

Their email address:*

Please list three personal goals you have for taking the Mindfulness-Based Stress Reduction Program:*

Please, what are the best days and times for you to receive a phone call from Irena Danys or from Rossana Magalhaes?*

Consent*

Mindfulness-Based Stress Reduction Program

INFORMED CONSENT AGREEMENT

The risks, benefits and possible side effects of the Mindfulness-Based Stress Reduction Program will be explained to me at the orientation meeting. This includes skill training in meditation methods as well as gentle stretching (yoga) exercises. I understand that if for any reason I am unable to, or think it unwise to engage in these techniques and exercises either during the weekly sessions or at home, I am under no obligation to engage in these techniques nor will I hold Irena Danys nor Rossana Magalhaes liable for any injury incurred from these exercises.

Furthermore, I understand that I am expected to attend each of the eight (8) weekly sessions, the daylong session and to practice the home assignments for
50-60 minutes per day during the duration of the training program.

I consent to the above Informed Consent Agreement.

Signature*

Please type your name below – this is your signature.

Phone

This field is for validation purposes and should be left unchanged.

Here is the technology you will need to take this MBSR live online program:

Download the Zoom app for free once you receive the Zoom Room link.
Zoom is a reliable and widely used platform for video conferencing and teaching.
A computer with a speaker, microphone, and camera.
High-speed internet connection
PLEASE NOTE: Tablets, phones, and Chromebooks are not recommended due to the limited online experience they offer.

NEXT STEP:Please, fill out this intake questionnaire. All information will be kept confidential.