Your Name (required)
Email Address (required)
Date of birth
All information is confidential:
Are you a veteran?
Are you able to work at present?
If YES please state occupation, if NO what prevents you from working
How did you hear of the Stress Reduction Program?
What are your interests in the Stress Reduction Program at this time?
What do you aim to gain/ change form participation in this program?
Can you commit to 1 hour of home mediation / exercises daily while participating in the 8 week program?
By requesting financial support, you have indicated that you are unable to afford the full registration fee at this time. We ask that financial aid recipients pay a minimum of 50% of the program fee (current prices can be found on our website). Because of the demand on our limited funds, please consider paying more if you can. What is the total maximum amount, above the minimum 50%, that you could afford to pay to participate in this program?
What is your approximate total household income annually from all sources?
How many people depend on your total annual household income?
Do you have a diagnosed medical condition as the primary reason you wish to
participate in this program?
Please state medical condition:
Are there significant medical expenses associated with your medical condition?
Approximately how much is the amount of your annual medical expenses which you must pay “out of pocket”, i.e., expenses that are not reimbursed by any form of insurance coverage?
Do you have a significant financial burden on you?
What is the approximate total annual expense of this financial burden for you?
Please select one of the below:
I have had no previous contact with this program.I have completed this program previously.I started the program previously, but was unable to complete the program.I have applied to the program previously, but was placed on a waiting list and did not start the program.