MBSR Registration Form

The information you provide below can help your MBSR Program Facilitator to ensure the Program is appropriate for you at the current time. If you have any concerns about participating in the program, please consult your health care professional.

Are there any life events that may affect your participation in the program? (death of a loved one, relationship breakdown). If yes, please provide brief details below.

Emergency Contact Information

Heath Care Information

Confidentiality Agreement

My MBSR Facilitator acknowledges that my privacy will be maintained to the full extent possible. The content of my private communications with the Facilitator will only be shared with my permission, or in circumstances where my MBSR Facilitator is required by law to breach confidentiality. These circumstances may include those where my Facilitator considers:

• I am at risk of harming myself or others;

• I am at risk of harming a child through acts of omission or commission (e.g. neglect, abuse).

  
  

My signature below confirms that:

• I have read and understand the above circumstances in which it is mandatory for a the MBSR Facilitator to breach confidentiality.

• I also give my permission for the content of the MBSR sessions to be recorded for MBSR Facilitator supervision purposes and I understand those recording will be destroyed after supervision sessions have been completed.