Name
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INFORMED CONSENTTITLE o...
When I’m walking, I deliberately notice the sensations of my body moving.
I’m good at finding words to describe my feelings.
I criticize myself for having irrational or inappropriate emotions.
I perceive my feelings and emotions without having to react to them.
When I do things, my mind wanders off and I’m easily distracted.
When I take a shower or bath, I stay alert to the sensations of water on my body.
I can easily put my beliefs, opinions, and expectations into words.
I don’t pay attention to what I’m doing because I’m daydreaming, worrying, or otherwise distracted....
I watch my feelings without getting lost in them.
I tell myself I shouldn’t be feeling the way I’m feeling.
I notice how foods and drinks affect my thoughts, bodily sensations, and emotions.
It’s hard for me to find the words to describe what I’m thinking.
I am easily distracted.
I believe some of my thoughts are abnormal or bad and I shouldn’t think that way.
I pay attention to sensations, such as the wind in my hair or sun on my face.
I have trouble thinking of the right words to express how I feel about things.
I make judgments about whether my thoughts are good or bad.
I find it difficult to stay focused on what’s happening in the present.
I pay attention to sounds, such as clocks ticking, birds chirping, or cars passing.
In difficult situations, I can pause without immediately reacting.
When I have a sensation in my body, it’s difficult for me to describe it because I can’t find the ri...
It seems I am “running on automatic” without much awareness of what I’m doing.
When I have distressing thoughts or images, I feel calm soon after.
I tell myself that I shouldn’t be thinking the way I’m thinking.
I notice the smells and aromas of things.
Even when I’m feeling terribly upset, I can find a way to put it into words.
I rush through activities without being really attentive to them.
When I have distressing thoughts or images I am able just to notice them without reacting.
I think some of my emotions are bad or inappropriate and I shouldn’t feel them.
I notice visual elements in art or nature, such as colors, shapes, textures, or patterns of light an...
My natural tendency is to put my experiences into words.
When I have distressing thoughts or images, I just notice them and let them go.
I do jobs or tasks automatically without being aware of what I’m doing.
I pay attention to how my emotions affect my thoughts and behavior.
I can usually describe how I feel at the moment in considerable detail.
I find myself doing things without paying attention.
I disapprove of myself when I have irrational ideas.
My knowledge of personality development is adequate for counseling effectively.
My knowledge of ethical issues related to counseling is adequate for me to perform professionally. ...
My knowledge of behavior change principles is not adequate.
I am not able to perform psychological assessment to professional standards.
I am able to recognize the major psychiatric conditions.
My knowledge regarding crisis intervention is not adequate.
I am able to effectively develop therapeutic relationships with clients.
I can effectively facilitate client self-exploration.
I am not able to accurately identify client affect.
I cannot discriminate between meaningful and irrelevant client data.
I am not able to accurately identify my own emotional reactions to clients.
I am not able to conceptualize client cases to form clinical hypotheses.
I can effectively facilitate appropriate goal development with clients.
I am not able to apply behavior change skills adequately.
I am able to keep my personal issues from negatively affecting my counseling.
I am familiar with the advantages and disadvantages of group counseling as a form of intervention. ...
My knowledge of the principles of group dynamics is not adequate.
I am able to recognize the facilitative and debilitative behaviors of group members.
I am not familiar with the ethical and professional issues specific to group work.
I can function effectively as a group leader/facilitator.
I’m disapproving and judgmental about my own flaws and inadequacies.
When I’m feeling down I tend to obsess and fixate on everything that’s wrong.
When things are going badly for me, I see the difficulties as part of life that everyone goes throug...
When I think about my inadequacies, it tends to make me feel more separate and cut off from the rest...
I try to be loving towards myself when I’m feeling emotional pain.
When I fail at something important to me I become consumed by feelings of inadequacy.
When I'm down and out, I remind myself that there are lots of other people in the world feeling like...
When times are really difficult, I tend to be tough on myself.
When something upsets me I try to keep my emotions in balance.
When I feel inadequate in some way, I try to remind myself that feelings of inadequacy are shared by...
I’m intolerant and impatient towards those aspects of my personality I don't like.
When I’m going through a very hard time, I give myself the caring and tenderness I need.
When I’m feeling down, I tend to feel like most other people are probably happier than I am.
When something painful happens I try to take a balanced view of the situation.
I try to see my failings as part of the human condition.
When I see aspects of myself that I don’t like, I get down on myself.
When I fail at something important to me I try to keep things in perspective.
When I’m really struggling, I tend to feel like other people must be having an easier time of it.
I’m kind to myself when I’m experiencing suffering.
When something upsets me I get carried away with my feelings.
I can be a bit cold-hearted towards myself when I'm experiencing suffering.
When I'm feeling down I try to approach my feelings with curiosity and openness.
I’m tolerant of my own flaws and inadequacies.
When something painful happens I tend to blow the incident out of proportion.
When I fail at something that's important to me, I tend to feel alone in my failure.
I try to be understanding and patient towards those aspects of my personality I don't like.
Your gender:
Your gender:-TEXT
Age:
Your ethnicity/race
Your ethnicity/race-TEXT
Your sexual orientation:
Your sexual orientation: -TEXT
Your current or previous program:
Your current or previous program: -TEXT
Please list the level of education you are currently completing:
Semesters of clinical practicum completed:
Briefly describe your theoretical orientation in a few words:
Please identify your philosophical/spiritual/religious tradition (if any) (i.e. Christian, Buddhist,...
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Yoga
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Dance
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Sing
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Listen to music
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Reading
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Progressive muscle relaxation
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Watching TV/movies
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Guided imagery
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Mindfulness meditation
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Jogging/running
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Journal writing
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Tai-chi
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Social supports
How often do you participate in these activities for each domain: personal life, professional life (... : Personal life-Get a massage
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Yoga
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Dance
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Sing
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Listen to music
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Reading
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Progressive muscle relaxation
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Watching TV/movies
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Guided imagery
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Mindfulness meditation
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Jogging/running
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Journal writing
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Tai-chi
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Social supports
How often do you participate in these activities for each domain: personal life, professional life (... : Professional life-Get a massage
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Yoga
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Dance
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Sing
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Listen to music
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Reading
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Progressive muscle relaxation
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Watching TV/movies
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Guided imagery
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Mindfulness meditation
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Jogging/running
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Journal writing
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Tai-chi
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Social supports
How often do you participate in these activities for each domain: personal life, professional life (... : Use with clients or teach them to practice activity-Get a massage
Please describe any formal training or education related to mindfulness and/or meditation:-Class or seminar specific to mindfulness
Please describe any formal training or education related to mindfulness and/or meditation:-Mindfulness training with practicum supervisor
Please describe any formal training or education related to mindfulness and/or meditation:-Religious practice
Please describe any formal training or education related to mindfulness and/or meditation:-Other (Please specify)
Please describe any formal training or education related to mindfulness and/or meditation:-Other (Please specify)-TEXT
Debriefing Form ...
Thank you for your time!