Registration Form Fall 2024 Saturday No Fee

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First Name

Last Name

Email

International Phone Number

City and Country (International Sign Ups) OR City and State (US Sign Ups only)

How did you hear about Imagine's Live Online MBSR Program?

Year of Birth

Emergency Contact Name and Phone Number

Are you currently seeing a therapist?

Our program includes "Meditation in Motion" (based on gently Hatha Yoga and Qigong). Please list any physical limitations or say None.

Do you have any psychological or emotional issues that are not stabilized?

What's important to you?

Please list personal goals for taking this MBSR program.

Please check any that apply to you.

Headaches

Aching joints and/or muscles

Respiratory difficulties

Digestive difficulties

Rapid or skipped heartbeats

Nervousness or anxiety

Lack of concentration or focus

Depressed

Difficulty relaxing

Considering suicide

Feeling desperation or hopelessness

Grieving

Difficulties with anger

Fatigue or weariness

Difficulty sleeping

Current substance abuse

Extreme hearing loss

None of the Above

Please list any of the above that are severe - if applicable.

Please use this space for comments and/or suggestions. (This is optional.)

I have read and understand these risks.

Checking this box and adding my name and today's date below signifies that I agree with the above.

Thank you for your registration! You will receive an email with details. Please proceed to your payment.

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