MBSR 8-Week Online Registration Form
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Mindfulness-Based Stress Reduction (MBSR)
With Karen Sothers, M.Ed., E-RYT

MBSR 8-Week Online Registration Form:

Please complete the following registration form and return to Karen Sothers by clicking on the send button at the bottom of this form.  Note:  If you navigate away from this page before you click send, your data will be erased and you will need to start over.

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.

If you have not already submitted your MBSR Online payment, please click HERE.


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    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.