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Mindfulness-Based Program with Trish Luck & Mick Krasner through Cancer Wellness Connection

Dear MBP workshop participant.
We well meet for the Four-week Online MBP Course Thursday Evenings 6.00-8.00pm May25, June 1, 8, & 15th
Please sign up for the course by filling out this confidential questionnaire. 
Your responses will remain confidential to the course facilitators only.  Anticipated participation in all 4 evening classes is necessary to register. 
By filling out this form you will help us maximize our effectiveness as your MBP instructors. We hope the experience of this program will be a beneficial one. With completion of this form we can confirm enrollment into the class.
Please skip any questions you do not wish to fill in.
Thank you and we look forward to guiding you through these next weeks.
Drs. Trish Luck and Mick Krasner
Email Trish or Mick if you have program specific questions:
patricia_luck@urmc.rochester.edu | michael_krasner@urmc.rochester.edu

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* 1. Please confirm that you will be able to attend all four evening sessions of the course - Thursdays May 25th to June 15th, 6-8pm

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* 2. Today's Date

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* 3. Name - first and last, preferred name used - and preferred pronouns

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* 4. Your year of birth

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* 5. Contact Details - Email Address and Telephone Number
These are needed so we can be in touch with ahead of the start date with necessary information including a workbook, the online class zoom link, and link to meditation recordings.

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* 6. Tell us about your Occupational, Health and Lifestyle:
     *Occupation/ Work status
      *Relationship status
      *Children
      *Ave Hours of sleep per night/ Quality of sleep

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* 7. Please indicate any medical conditions or physical injuries/limitations that might impact participation in this course? (We will engage in some basic mindful movement practices that will involve floor work on a yoga mat or blanket. These can be tailored to your particular needs.)

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* 8. Are you currently undergoing therapy for stress/mental health reasons?
If so might any of this be impacted by an intensive meditation program?

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* 9. What kind of exercise do you manage to do each week, if any/ Frequency?

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* 10. Do you or have you ever meditated or practiced yoga? If so please provide some details.

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* 11. What do you care most about in your life?

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* 12. What gives you most pleasure in your life?

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* 13. What are your greatest worries or stressors?

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* 14. What is your main reason for participating in this program?

0 of 14 answered
 

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