Graduate Drop In Registration Name * First Name Last Name Email * Phone * (###) ### #### 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? * Is it OK to leave a voicemail on the phone number you listed? * Yes No 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" * 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 Thank you!
