Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you currently seeing a therapist? *

YES

NO

Is your mental professional aware of your interest in participation in this program?

YES

NO

Mental Health Professional Name (will be contacted only when needed and with your permission) *

First Name

Last Name

Are you currently participating, or have you participated before, in any support group? *

YES

NO

What is your experience with Mindfulness? *

None

Beginner

Intermediate

Advanced - Expert

Do you practice or teach mindfulness, and other related practices? *

Practice

Teach

Practice and Teach

I neither practice nor teach

Has your level of Physical activity changed due to grief and how?

YES

NO

Has your Sleep Quality changed due to grief and how?

YES

NO

Have your Eating Habits changed due to grief nand how?

YES

NO

For group events: Are you able to attend a group session, which may be highly emotional experience for some?

if you are seeing a therapist, please also check in with them. Group practices may be both healing and also emotionally charging. Respecting both its impact on you. and this impact on others, please note how it may affect your participation.

Yes

No

For group events, EMERGENCY CONTACT:

First Name

Last Name