MBSR for Musicians – Intake Form

Thank you for your interest in the 8-week Mindfulness-Based Stress Reduction (MBSR) course for musicians.
This form will help us prepare for our intake conversation (approx. 15 minutes) and ensure that the training is a good fit for you.
All information is strictly confidential.

First Name *

Last Name *

Email *

Street Address

City

Country

Postal code

Date of birth *

Have you had any previous experience with mindfulness, meditation, yoga, or related practices? *

YES

NO

If yes, please describe briefly:

What are your main reasons for joining this MBSR course? *

Practical Considerations

The program includes 30–45 minutes of daily home practice. Do you feel able to commit to this? *

YES

NO

Comments (optional):

Will you be able to attend all 8 sessions and the silent retreat day? *

YES

NO

If no, please mention the dates you may miss:

Health and Well-being

Have you ever experienced depression, anxiety, or other psychological difficulties? *

YES

NO

If yes, were you treated? How is your situation now?

Are you currently receiving support from a psychologist or therapist? *

YES

NO

Have you experienced any traumatic events that still affect you? *

YES

NO

If yes, please describe briefly (optional):

Do you feel comfortable participating in a group and sharing your experience when appropriate? *

YES

NO

Is there anything else you’d like the teacher to know before the course begins?

Agreement

I understand that this MBSR program is not a therapy or treatment. *

YES

I take full responsibility for my participation in this program. *

YES

Once you submit this form:

You will receive an email with payment instructions
You’ll be invited to book your intake conversation via Zoom

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge and I confirm that I have read and agree to the Terms & Conditions and Privacy Policy of the MBSR for Musicians program.
I understand that my registration for the MBSR for Musicians program will only be finalized after completing the intake conversation and full payment.

I agree to be contacted by email regarding my participation in the training.

KvK Nr. 59280298

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