Perinatal Mindfulness Group – Participant Intake Form

Thank you for completing all sections of this form so that I can provide a supportive learning experience. All info shared is fully confidential and will only be read by me (Stephanie Curran - instructor).

First & last name / Cell phone

Address (including city) & Occupation

Emergency contact name & phone number

Please indicate which class you will be attending:

Group A - Primary Infertility: Thursdays 5:00-6:30pm (May 9 - June 13, 2024)

Group B - !st Trimester Loss: Thursdays 5:00-7:00pm (May 9 - June 13, 2024)

Group C - Secondary Infertility: Thursdays 7:15-9:15pm (May 9 - June 13, 2024)

How did you hear about this course? (please be as specific as possible)

Please tell me a little about yourself and what brings you to this class at this time. Briefly describe any stressors, worries or concerns you are experiencing.

What are three ways you hope to benefit from this course?

Do you have anxiety or depression, suicidal episodes, post-traumatic stress or active drug/alcohol dependency? If so, please describe and list any supports you have worked with in the past or are currently engaged with now.

A commitment and intention to attend all classes is required (missing one class if fine). Are you able to attend all sessions? (If no, please list dates)

Thank you for registering for the Perinatal Mindfulness Program. Your form has been submitted. Please check your email for further communication from the instructor.