UNWINDING ANXIETY

PARTICIPANT REGISTRATION FORM

Name

First Name

Last Name

Phone

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INFORMED CONSENT

Unwinding Anxiety is an educational program applying mindfulness to habit change. We are here for those who find that the companionship of others deepens their own commitment and engagement with the challenge of habit change. We are delighted to share this exploration with you. As with so many challenging endeavors, the key to lasting progress is to begin again, again and again. As you join this class for improved health and personal growth, it is important to take care of yourself as you practice. We encourage you to try all the materials provided, seeing which exercises, tools and skills work best for you, which may change or vary over time. What follows are reminders and agreements about the context and limitations of our Unwinding Anxiety class. Mindfulness practices are not a substitute for medical or psychological treatment. Engaging in any activity involves a risk of adverse reactions which cannot be entirely eliminated. Consult your physician if you have any health concerns. (Please check the boxes below)

I agree to seek professional support if I experience distress that is difficult to manage.

I agree that my participation in the Unwinding Anxiety course and any specific practice is entirely voluntary. I will be responsible for observing and attending to any pain or discomfort by pausing, going at my own pace, respecting my own limitations, or making other adjustments for my own safety or comfort and communicating with the teachers as needed. I hereby assume the entire risk of participating in this course and release the creators and teachers of this program of any liability, loss, or injury in connection with my involvement with this course.

Privacy Policy: We respect the private nature of your personal information. We will not share any of your personal data ever. (Please check the box below)

I understand the privacy policy above and I agree to protect the confidentiality of any personal information about other group members gained during this class.

I give permission to Laurence Magro and Nancy Logue to communicate information regarding the class via email

Cancellations and Refunds: 50% refund before January 19. No refund once classes start. (Please check the box below)

I understand the refund agreement stated above.

Electronic Signature

By typing your name on this line, you agree to the policies and conditions stated above.

Date

YYYY

CONFIDENTIAL QUESTIONNAIRE

The following information helps us provide you with the best services possible. Any information you choose to provide will help us assist you with common issues that may arise during the course.

1. What is you main reason for wanting to participate in the Unwinding Anxiety course?

2. What brings you the most pleasure in life? What do you care about most?

3. Briefly describe the major stressors in your life? (e.g, health, family, relationships, work, financial)

4. Do you take prescription medication? (Yes/No) If yes, please list below.

5. Are you currently, or have you ever been in psychotherapy/counseling? (Yes/No) If yes, please describe briefly

6. What is your relationship to alcohol and/or mood enhancing drugs?

7. Have you experiences personal abuse (physical, sexual, verbal) and/or the witnessing of it?

8. Do you have any prior meditation and/or mindful movement experience (No prior experience required)