Long Island Center for Mindfulness
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    Mindfulness-Based Stress Reduction Questionnaire

    Thank you for filling out this questionnaire. I realize the personal nature of some of these questions. Please be assured that the completed forms are kept in strict confidence. I, Cory Muscara, am the only person who sees this information. Any information you are willing to provide will be of great help to me in assisting you with common issues that may arise. No record of this questionnaire, other than contact information, will be kept after the course is completed.

    Informed Consent Agreement

    The benefits and risks of the Mindfulness-Based Stress Reduction Program were explained to me in detail. This includes skill training in relaxation and 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 Family Medicine Associates or at home, I am under no obligation to engage in these techniques nor will I hold the above named facility or its instructor liable for any injury incurred from these exercises.
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