Mindfulness-Based Stress Reduction Form

Mindfulness Based Stress Reduction Program

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Name *

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Line 2

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This application begins your MBSR journey. Taking time to answer the questions is, in a way, your first mindfulness practice. First, be mindful of what drew you to this programme. It may be that you are curious, perhaps you have something on your mind or a life or health challenge. Perhaps you simply want to be more present and engaged. Take time to consider the following questions as best you can.

1. What is it that draws you to this programme and what are you hoping to get by the end of the programme? *

2. While we tend to take our core strengths for granted, it is useful to know and recognise these for ourselves. Our core strengths can form a base for self-improvement. Perhaps thinking what a good friend or close family member say they appreciate about you. Take time to consider this (and no need to be modest.) *

3. One of the main challenges about this programme is finding 40 – 45 minutes each day to practice. Weekday practice times may be different to weekend times. Writing when you can practice in a diary or journal may help you keep the daily commitment to yourself. And as in any diary there may be times where we need to switch appointments and meetings and this 40 – 45 minutes per day is your appointment with yourself. *

4. What do you enjoy in your life that feels nourishing for you? *

5. What does happiness mean to you personally? *

Part 2. Medical 6. Do you have any health issues that the course facilitator should be aware of? (For example, asthma, allergic reactions, epilepsy, blood pressure, depression, anxiety, anger issues?) *

. Are you currently on any prescription medication? If so, please specify? *

8. Please indicate and specify the name and number of your GP or significant other that can be contacted in case of a health or safety issue. *

9. What are the biggest stresses/challenges in your life at the moment? How does this affect you personally? *

10. Have you had any significant life changing events over the past year? For example, the death of someone close to you, separation / divorce, changing jobs/ unemployment. *

11. Do you have support in your life? Family, Friends, Counsellor? *

12. How is your overall health? For example, sleep, digestion, headaches, caffeine intake, smoke or alcohol intake, exercise, relaxation, diet? *

13. If you need special seating or wheelchair access please let us know and we will do our absolute best to accommodate you. *

Anything else you feel is relevant, please let us know *

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Mindfulness Based Stress Reduction Program

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