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Contact Information

Contact Information will be kept strictly confidential. It will not be shared or used for any purpose other than application to the 8-WEEK MINDFULNESS-BASED JOY PRODUCTION ONLINE COURSE.

First & Last Name *

Email Address *

Confirm Email Address *

Street Address *

City *

State/Province

Country

Phone *

Personal Information

Personal Information will be kept strictly confidential. It will not be shared or used for any purpose other than application to the 8-WEEK MINDFULNESS-BASED JOY PRODUCTION ONLINE COURSE.

Occupation *

Nationality *

Relationship Status *

Do you have children? *YesNo

How did you learn about this 8-WEEK MINDFULNESS-BASED JOY PRODUCTION ONLINE COURSE? *

What is you main reason for participating in this program? *

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If you currently have a meditation practice, please describe:

Are there any physical injuries or conditions that may affect your participation? *YesNo

If Yes, please describe:

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Are there any emotional or psychological conditions that may affect your participation? *YesNo

If Yes, please describe:

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Are you currently in psychological or psychiatric treatment? *YesNo

If Yes, please describe:

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Are you currently taking prescription medication? *YesNo

If Yes, please describe:

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Do you have a history of substance abuse? *YesNo

If Yes, please describe:

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Please list 3 personal goals you have for taking this online course. *

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Complete and Send

I understand that in this 8-WEEK MINDFULNESS-BASED JOY PRODUCTION ONLINE COURSE I will be engaging in mindfulness-based and yoga-based methods for stress reduction. These methods have been shown to be helpful in reducing stress and increasing well-being, but are not a replacement for professional medical care. Results will vary among participants. I understand that if for any reason I feel it unwise to engage in these techniques in the weekly sessions or on my own, I am under no obligation to do so, nor will hold instructor Patrick Mitchell liable for any injuries or harm incurred as a result of participating in the program. *YesNo

Signed *

Date *

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