MBSR Registration Form - Jill Dunkley (CIAYT)

Please fill in the form below. All information provided is to determine whether the program is suited to the applicant and will be kept private and confidential.

Please complete the form below

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In order to establish a daily formal practice it is necessary to be clear about your vision. Why are you doing this program? How do you see yourself as a result of practicing mindfulness? Perhaps you want to be peaceful, calm, relaxed, a better parent, partner, friend, healthier, more balanced. Spend a few quiet moments reflecting then please write down your goals below for the MBSR program. *

The cultivation of knowledge and the development of any skill require deliberate, consistent attention on the part of the learner. Therefore the transformational backbone of MBSR is the daily home assignments. These include formal and informal practices systematically sequenced and assigned throughout the course of the program. The basic ground rule is that everybody participating in the program practices -- 30 minutes per day, six days a week. Discussing the obstacles and finding creative ways to fit these practices into an already busy day will be a key component of this program. On a scale of 0 to 10, please write down the number that indicates how committed you are to yourself in making changes you want to make toward your vision during the 8 weeks of the program.