9d MBSR 8-Week Online Registration Form
1432
wp-singular,page-template-default,page,page-id-1432,page-child,parent-pageid-1434,wp-theme-bridge,theme-bridge,bridge-core-3.3.4.6,woocommerce-no-js,qode-optimizer-1.0.4,qode-page-transition-enabled,ajax_fade,page_not_loaded,boxed,vertical_menu_enabled,,qode-title-hidden,side_area_uncovered_from_content,qode-smooth-scroll-enabled,columns-3,qode-theme-ver-30.8.8.6,qode-theme-bridge,disabled_footer_top,qode_header_in_grid,wpb-js-composer js-comp-ver-8.7.2,vc_responsive

Mindfulness-Based Stress Reduction (MBSR) Online Program
with Karen Sothers, M.Ed., E-RYT

MBSR 8-Week Online Registration Form

Please complete the following registration form and return it to Karen Sothers by clicking the “Send” button at the bottom of this form.

⚠️ Important: Please complete the form in one sitting. Your responses are securely sent to Karen once you click “Send.” If you leave this page before sending, your information will not be saved and you will need to re-enter it.

Please be assured that Karen will not share your information with anyone else.  If there is information that you are not comfortable recording on this form, please click HERE and email Karen to set up a time to talk by phone.


    WebsitePhysicianTherapistFriendFamilyOther

    To best support you during MBSR, it is helpful to have a general understanding of current health conditions, past health history, and significant life events.

    Are you currently engaged with (or have you been in the past) counseling, therapy, psychotherapy or psychiatric care?
    - - If yes, please describe

    Do you have any experience with yoga?
    - - If yes, please describe

    Do you have any experience with meditation or relaxation methods?
    - - If yes, please describe


    Do you have children?

    Do You Smoke? -- If yes, how much

    Sleep quality
    Hours per night

    Do you have challenges with falling asleep?

    Do you have challenges with going back to sleep if you wake up too early?

    Do you consume alcohol?
    - - If yes, Avg. drinks per week

    Personal Goals for MBSR Course*


    When you are ready to submit your MBSR Online Registration Form to Karen, please click on the SEND button below and your information will be transmitted over an encrypted connection.

    Note: After clicking SEND below, please wait a moment for confirmation that your message has been sent before you navigate away from this page.