MBSR Course Application

Please fill in the form below. All information provided is to determine whether the program is suited to the applicant and will be kept private and confidential.

Name

First Name

Last Name

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Address

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In order to establish a daily formal practice it is necessary to be clear about your vision. Why are you doing this program? How do you see yourself as a result of practicing mindfulness? Perhpas you want to be peaceful, calm, relaxed, a better parent, partner, friend, healthier, more balanced. Spend a few quiet moments reflecting then please write down your goals for the MBSR program.

The cultivation of knowledge and the development of any skill require deliberate, consistent attention on the part of the learner. Therefore the transformational backbone of MBSR is the daily home assignments. These include formal and informal practices systematically sequenced and assigned throughout the course of the program. The basic ground rule is that everybody choosing to participate in the program practices for a minimum of 30 minutes per day, six days a week. Discussing the obstacles and finding creative ways to fit these practices into an already busy day will be a key component of this program. On a scale of 0 to 10, please write down the number that indicates how committed you are to yourself in making changes you want to make toward your vision during the 8 week program.