UAMS MBSR Registration and Consent Online Submission Form

Online Registration and Consent Form

Your privacy will be respected. Personal data submitted on this Online Form will be deleted permanently after 24 hours. Your submissions will be emailed to the Instructor immediately. Responses are kept confidential and will only be shared with the instructor for the course and purged after being reviewed. You may be contacted for a brief phone interview before the course begins. You will be asked to sign an informed consent agreement so the instructor may record audio of themselves for training purposes.

Name * Required
First Last
Gender Identity
- Female
- Male
- Prefer not to answer
- Preference
Preferred Gender Identity
Ethnicity/Race
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Pacific Islander
- White
- Hispanic or Latino
- Other
Other Ethnicity/Race
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email * Required
Phone (best contact number) * Required
1. What is your main reason for participating in the MBSR Program? * Required
2. Occupation: * Required
3. Date of Birth - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
4. Family Information: * Required
- Single
- Married
- Divorced
- Widowed
5. Do you have children? * Required
- Yes
- No
5a. If with children...how many and ages? * Required
Please indicate how many children and their ages.
6. Do you have close friends? * Required
- Yes
- No
7. Sleep quality: * Required

Please describe the current quality of your sleep?
8. Do you smoke? * Required
- Yes
- No
9. Caffeinated drinks per day: * Required

Please estimate the amount of caffeine you consumer per day
10. Do you exercise? * Required
- Yes
- No
11. Do you use drugs or alcohol? * Required
- Yes
- No
11a. If so, how much? * Required

Please provide an estimate of your consumption
12. Do you have a history of substance abuse? * Required
- Yes
- No
13. Do you take prescription medications? * Required
- Yes
- No
13a. If so, please list
14. Are you currently engaged in psychotherapy? * Required
- Yes
- No
14a. If no, have you been in therapy during the last three years?
- Yes
- No
15. Previous overnight hospitalizations? * Required
- Yes
- No
15a. If so, please list, including the year/s * Required
Medical/Surgical: Psychological:
Please list your previous hospitalizations for any Medical, Surgical and/or Psychological situations, including the year/s.
16. During the last MONTH have you:
16a. Considered suicide? * Required
- Yes
- No
16b. Sought psychiatric help? * Required
- Yes
- No
16c. Had thoughts of death or dying? * Required
- Yes
- No
16d. Had urges to beat, injure or harm someone? * Required
- Yes
- No
16e. Had urges to smash or break things? * Required
- Yes
- No
16f. Had spells of terror or panic? * Required
- Yes
- No
17. What do you care about most? * Required
18. What gives you the most pleasure in your life? * Required
19. What are your greatest worries? * Required
20. Please list three personal goals you have for taking the MBSR Program: * Required
1. 2. 3.
21. How did you hear about this program? * Required
Consent Section
Informed Consent Agreement * Required
The risks, benefits and possible side effects of the Mindfulness-Based Stress Reduction Program were explained to me. This includes skill training in meditation methods as well as gentle stretching (yoga) exercises. I understand that if for any reason I am unable to, or think it unwise to engage in these techniques and exercises either during the weekly sessions at UAMS or at home, I am under no obligation to engage in these techniques nor will I hold the above named facility liable for any injury incurred from these exercises. Furthermore, I understand that I am expected to attend each of the eight (8) weekly sessions, the daylong session and to practice the home assignments for 40-60 minutes per day during the duration of the training program.
Email Communication Consent * Required
As a participant in the Mindfulness-Based Stress Reduction Program, you may wish to communicate with your instructor via email on occasion. In order to ensure your privacy, we request that you give written permission for this form of correspondence.
Instructor Recording of Class for Educational Purposes Consent * Required
I understand that the Instructor may record the session for academic training and educational purposes. I consent to video/audio recordings being made of these sessions and to be used for improving the MBSR educational program. Every effort will be made to ensure professional confidentiality and that any use of video/audio tapes, or descriptions of video/audio tapes, will be for educational purposes only and in the interests of improving professional standards through research or training. Every effort will be made to protect the anonymity of all those involved in the sessions.
Acknowledgment and Waiver of Liability * Required
I accept full responsibility for my health and voluntarily complete this Acknowledgement and Waiver of Liability. I understand and agree that the services and tools offered in the University of Arkansas for Medical Sciences Mindfulness Program offered by the teachers of the University of Arkansas for Medical Sciences Mindfulness, its officers, employees and agents are not intended to replace or be substituted for medical or psychiatric care. It is recognized that the trainings inherent in the programs may at times make participants feel vulnerable. Mindfulness programs are not therapeutic interventions for psycho-pathological disorders as defined in the DSM and are not intended as such. By completing this release and consent I assume all risk for any physical or mental consequences of participating in the program. By signing this release I also specifically and expressly agree to hold harmless, indemnify and release the teachers of the University of Arkansas for Medical Sciences Mindfulness Program, its officers, employees and agents from any and all liability for the results of the educational guidance that will be or have been provided. Moreover, I acknowledge that the particulars shared in these classes by other participants are to be maintained as confidential. I will not blog or otherwise report on content shared in these classes in any form of media.
Consent * Required
I agree and consent to the Agreements above and I certify that this form is being completed by the registrant:
Comments
This field is for validation purposes and should be left unchanged.

Online Registration and Consent Form

16. During the last MONTH have you:

Consent Section