MBSR All Day Retreat Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Emergency Phone Number * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about this All-Day MBSR Session ( Please specify) * When did you complete the last 8 Week MBSR or MBCT Program? * Where did you complete the last 8 Week MBSR or MBCT Program? * What was the name of your MBSR or MBCT teacher? * Currently seeing a Counsellor or Psychologist? If so, are you currently actively experiencing symptoms (e.g., flashbacks, nightmares, difficulty with attention) Yes No GP and Clinic Name * Did you attend a minimum of 5 out of the 8 weekly MBSR or MBCT sessions? Yes No Have you attended an All-Day Session before? Yes No Do you have close friends or family in the area? How is the quality of your sleep? (please describe) * Do you take prescription medication? (If yes, please list) * Have you experienced any significant changes in: * Medical/Health Matters Psychological Matters None If you checked the medical and/or psychological box(s) in the previous question, then please elaborate below. Otherwise, indicate "not applicable" * Any previous overnight hospitalization? Yes, for medical/surgical reason(s) only Yes, for psychological reason(s) only Yes, for both medical/surgical AND psychological reasons None If you answered yes to the above question, please elaborate. Otherwise, indicate "not applicable" * Have you experienced any of the following in the past (check all that apply): Considered and/or attempted suicide Have urges to harm someone Have experienced panic attacks I have not experienced any of the above Please elaborate on the above question, or indicate "not applicable" if you selected "No"(required) * Do you have a history of substance abuse? * Yes No Do you have a history of trauma? * If so, are you currently actively experiencing symptoms (e.g., flashbacks, nightmares, difficulty with attention). Yes in the past, but no current symptoms Yes and I am currently experiencing symptoms No What do you consider to be your strengths? (please list at least three) * Method of payment for program fee ($50) * Interact e-Transfer $50 (for within Canada only) Credit Card Payment $55 ($50 + $5 processing fee) Is it OK to leave a voicemail on the phone number you listed? * Yes No Privacy and Copyright: I understand that there is no recording permitted during the session * This means no video recording, no audio recording, and no photos/pictures permitted Yes, I understand and agree Anything else you want me to know? (Optional) I confirm that I have read and agree to Presencia's Privacy Policy * Yes, I confirm Please note: you will be notified of your registration status within 3-4 business days * If you did not hear back from me by then, please e-mail me at info@presencia.ca Yes, I understand Thank you!
