MBSR Participant Questionnaire

Full Name:

Email address

Phone Number:

Address:

Occupation

Age:

How did you find us?

What current challenges have brought you to the MSBR course?

What has helped?

What is the quality of your sleep?

What challenges might come up in finding time for the home practice each day?

Have you experienced things in your life that were overwhelming, either earlier on in life, or more recently?

Can you let me know any medications you are currently taking for physical/mental health reasons?

Are you currently seeing a counsellor or therapist?

If you have been referred to the course by a health professional can you please let us know their name and contact number / name of clinic.

What strengths do you bring into learning something new like this?

I give my informed consent to participate in the course (as I have been informed of the risks and benefits of doing MBSR outlined in my confirmation email).

MBSR Questionnaire