Mindfulness-Based Stress Reduction Orientation Registration

Everything you discuss on this form, or in the future with a Whole Connection therapist, will be kept confidential and stored only in our locked locations. Your privacy is important to us, but we are also trying to make sure that our services are a good fit for you.

Please complete the form below

How did you hear about us?

If you selected other above, where or who did you hear about us from?

Name

First Name

Last Name

Date of Birth

Please Supply Month/Day/Year we use this to make sure you are in network with us

Gender Pronouns (if you wish to share)

This will help us make sure we identify you correctly. ex) She/Her/Hers, they/them/theirs

Email Address

Best phone number to reach you at

Can we leave you a voicemail, text, or email message on this number and email address?

Yes to Email

Yes to Voicemail

Yes to Text

No to All

Do you have any physical disabilities that might make it hard to walk up stairs?

We currently are located on the second floor, but do have an office we can use on the 1st floor if needed

Is there anything else you would like us to know? This could be how you identify, certain preferences regarding therapists, or major stresses in your life.

This could be a recent event or something about you that you want us to know like preferences in therapists or how you might identify