Pre-Class Questionnaire for MBSR

Thank you for filling out these forms. I realize the personal nature of these questions. Please be assured that the completed forms are kept in strict confidence. I am the only person who sees this information. Any information you are willing to provide will be of great help to me in assisting you with common issues that may arise. I will delete the form at the end of the course and other than contact information no record of any of your information will be kept.

Pre-Class Questionnaire for MBSR

Family Information

Do you have children?

Do you have close friends?

Do you have old, long-term friends?

Do you smoke (cigarettes)?

Do you exercise?

Do you eat a balanced diet?

Do you currently use alcohol or recreational drugs?

Any History of Addiction?

Do you have a history of trauma?

*If yes are you actively experiencing symptoms that feel connected to this trauma? flashbacks, nightmares, having difficulty with attention etc.

Are you currently in therapy?

If yes, does your therapist know you are taking this course?