Mind-Body Stress Reduction Program. Masterpeace Studios
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- Shauna Bryan
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1 STUDIO ADDRESS Arden Mead Youth and Community Center 17 Selma Ave. Webster Groves, MO MAILING ADDRESS 171 Hull Ave. Webster Groves, MO Program: Mind-Body Stress Reduction Class Enrolling : Mind-Body Stress Reduction Program Thank you for filling out the attached forms. We realize the personal nature of these questions. Please be assured that the completed forms are kept in strict confidence. Name: Address: Telephone #: Home ( ) Work ( ) Cell ( ) Please indicate which number is the best to reach you. Where did you hear about the Mind-Body Stress Reduction Program? Copyright 2008 All Rights Reserved 1
2 Name Health Information Form 1. Please check the word that best describes the current state of your health: Poor Average Good Great Please check all of the following that apply to you: Addiction to drugs/alcohol Hearing Loss Anxiety disorder Heart trouble AIDS/HIV Hernia Allergies Hypertension Arthritis Hypoglycemia Asthma Orthopedic problems Back pain Respiratory problems Cancer Sleep disorders Suicidal thinking Chronic fatigue syndrome Surgery (recent) Chronic pain Fibromyalgia Thyroid/endocrine problem Colitis Urinary disease Diabetes Therapy/counseling Depression Tuberculosis Digestive problems Eating disorder Epilepsy Emphysema Headaches Glaucoma Gastritis/ulcer For Women: PMS or irregular periods Menopausal symptoms Hot flashes Copyright 2008 All Rights Reserved 2
3 Please describe any other health or medical conditions below: 1. Are you taking a long-term prescription or over-the counter medication? Y or N If so, please list the medication and the reason you are taking it. 2. Occupation: 3. of Birth: (MM/DD/YEAR): 4. Gender (please circle): MALE FEMALE 5. Do you smoke? Caffeinated drinks per day: 6. Do you eat a balanced diet? 7. Do you exercise? Do you use drugs or alcohol? 8. What is your main reason for participating in the Mind-Body Stress Reduction Program? 9. Please ask any questions or voice any concerns that you have about participating in any part of this class, (ie: yoga, meditation, half day retreat, anything) Copyright 2008 All Rights Reserved 3
4 Mind-Body Stress Reduction Program INFORMED CONSENT AGREEMENT The risks, benefits and possible side effects of the Mind-Body Stress Reduction Program were explained to me in detail. This includes skill training in relaxation and meditation methods as well as gentle stretching (yoga) exercises. I understand that if for any reason I am unable to, or think it unwise to engage in these techniques and exercise either during the weekly sessions at or at home, I am under no obligation to engage in these techniques nor will I hold the above named facility liable for any injury incurred from these exercises. Furthermore, I understand that I am expected to attend each of the six (6) weekly sessions, the half day long session and to practice the home assignments for minutes per day during the duration of the training program. Please Print Name Participant s Signature Parent or Legal Guardian (If a minor) Mind- Body Stress Reduction Policies and Procedures We highly recommend attending a Free Introduction to Mindfulness Class prior to registering for the 6 week Mind-Body Stress Reduction Class. The completed orientation packet and all registration fees must be submitted at least one week prior to the start of the first class. CANCELLATION POLICY: If cancellation is after the first class a refund will be provided less a $50.00 cancellation fee. There will be no refunds if cancellation is after the second class. CLASS MAKE-UP: Any missed class can be made up in the next session of MBSR. All missed classes must be made up within the next two MBSR sessions following the session which you are registered. The complete MBSR manual and the CD s are trademarked and copyrighted by. Any copying or unauthorized use of these materials is forbidden. _ Name Copyright 2008 All Rights Reserved 4
5 Communication Consent As a participant in the Mind-Body Stress Reduction Program at, we may wish to communicate with you via to distribute administrative materials and general communication. Please provide your approval and address below. I give my permission to communicate via . I DO NOT give permission to communicate via . address: In order to ensure your privacy, we will communicate with you either in person or over the telephone regarding any personal aspects of the mind-body stress reduction program experience. Signature: : Release and Consent to Photograph Subject s Name: Address: Phone Numbers: (H) (W) I understand that routinely promotes the educational, health and spiritual benefits of participating in its programs and other activities. I also understand that may write stories that may appear in publications. I hereby consent to being the subject of photographs taken during class and hereby release and its agents from any and all claims for damages for liable, slander, invasion of privacy or any other claim based upon the use of my image and likeness as stated above. Signature Copyright 2008 All Rights Reserved 5
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Western Center Eye Care 2720 Western Center Blvd Ste 316 Fort Worth, TX 76131
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