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* 1. What is your name?

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* 2. What is your email?

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* 3. Do you currently meditate?  (It is completely fine if you are new).

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* 4. How did you hear about the 4-Week Intro to Mindfulness Course?

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* 5. What holidays (if any) do you celebrate?

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* 6. Are there any areas of your life that are particularly stressful right now?

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* 7. What are your tools for managing stress?

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* 8. Are you willing to commit to 5 minutes/day of self practice for four weeks?

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* 9. This program meets for four Mondays at 7pm in Hancock Park.  I am applying for:

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* 10. Thank you for submitting your request!  We will be in touch asap.

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