Intake Spring 2021 | imaginemindfulness

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Imagine MBSR Intake Form Spring 2021

WEDNESDAYS April 7 through May 26

Please check any that apply to you.

Headaches

Aching joints and/or muscles

Numbness

Respiratory difficulties

Digestive difficulties

Rapid or skipped heartbeats

Nervousness or Anxiety

Lack of concentration or focus

Depressed

Difficulty relaxing

Feeling desperation or hopelessnes

Grieving

Outburst of anger

Loss or gain in appetite or weight

Fatigue or weariness

Difficulty sleeping

None of the above

I have read and understand these risks.

Please sign by checking this box and writing your name below.

Please check this box and write the date below.

Thank you for submitting! We will get in touch with you soon to let you know if your Intake Form has been accepted. Please pay your registration fee at that point.