Name
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First Name
Last Name
Email Address
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DOB
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Please provide your date of birth.
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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*Your. information will not be shared.
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Relationship Status
Single
Partnership
Married
Divorced
Widowed
Occupation/Work Status
Emergency Contact
First Name
Last Name
Emergency Contact Phone #
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Have you ever been pregnant?
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If you answered yes:
Please provide your number of pregnancies, miscarriages, and/or children.
Are you currently under medical treatment or supervision?
If yes, please explain.
Medications
Please list any medications you are currently taking.
Surgeries
Please provide a list of any surgeries you have had.
How many hours of sleep, on average, do you get at night?
4 or less
4-6
6-8
8 or more
How many days/week do you exercise?
Never
2 days or less
3-5
Every Day
What kind of exercises do you do?
Do you smoke cigarettes?
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If yes, how many per day?
Do you drink caffein regularly?
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If yes, how many drinks per day?
Do you drink alcohol or use recreational drugs?
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If yes, how often?
History of substance abuse?
If relevant.
Are you currently undergoing therapy for mental health reasons?
if yes, please explain.
Therapist Name
If you answered yes to the question above.
First Name
Last Name
Therapist Phone #
(###)
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What gives you the most pleasure in your life?
What are your greatest anxieties?
Is there anything else that you might want me to know about you?
Is the information you provided above accurate to the best of your knowledge?
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Disclosure Statement and Informed Consent Degrees and Credentials of Julie Maus, LSW
• BA in Psychology from the University of Notre Dame
• Masters in Social Work from Colorado State University
• Colorado State Licensed Social Worker
• Completed the MBSR Training program through the Centre for Mindfulness, Toronto
Your rights as a Client The practice of licensed social workers is regulated by the Mental Health Licensing Section of the Division of Professions and Occupations. The Board of Registered Social Workers can be reached at 1560 Broadway, Suite 1350, Denver, CO 80202. 303-894-7800. As a client, You are entitled to information about the program. MBSR is an empirically supported, educational, and experiential training. It is not psychotherapy. It is taught in a group format and includes various forms of meditation practices as well as mindful movement/yoga. MBSR is not intended to replace medical or psychological treatment.
Confidentiality: The information provided by the student and other students during class is legally confidential and cannot be released without the student’s consent. There are exceptions to confidentiality, some of which are child abuse and imminent danger to self or others. For more information, The Mental Health Practices Act (CRS 12-43-101) is available at www.dora.colorado.gov.
Cancellations: Attending the eight week MBSR course requires a commitment to attend all eight classes, including the retreat in the sixth week. If a class is missed, please contact me to schedule a time to review the material, at my hourly rate of $100/hr, before the next class. The best time to reach me is 9am -3pm, Monday-Friday by email at julie@mindfulmaus.com. If two classes are missed, the participant will be asked to withdraw from the course with no refund although he or she may apply the funds to a future MBSR class. If a participant does not want to continue the course after one class, he or she will receive 50% reimbursement.
Expectations: I understand that it is my responsibility to let the MBSR teacher know of any concerns that may arise during the course, and when necessary seek appropriate treatment. I assume all risk for any physical or mental consequences of participating in this MBSR program. As a mental health professional, my MBSR teacher, Julie Maus, may advise me to seek medical and psychological treatment as a part of continuing in the MBSR program, or even require me to discontinue with the MBSR course.
Have you read and understand the disclaimer above?
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By checking Yes in the box below, you are agreeing to the disclosure provided above.
Todays Date
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