Contact | East Vancouver Psychologist

How did you hear about me?

How can I help you?*

If needed, provide more info about your availability below:

Anything else you'd like me to know?

MBSR Graduate

Please fill out the following application form. All responses will be kept in the strictest confidence. Once complete, click the SEND button. Fields marked with an * are required.

Which program are you registering for?*

Emergency Contact Phone Number*

How did you hear about this session? (Please specify)*

When did you complete the last eight-week MBSR or MBCT program? (if not, please state "not-applicable")*

Where did you complete your last MBSR or MBCT program (if not, please state "not-applicable")?*

What was the name of your MBSR or MBCT teacher (if not, please state "not-applicable")?*

Family Doctor (GP) and Clinic name*

for Emergencies only

If you checked the medical and/or psychological box(s) in the previous question, then please elaborate below. Otherwise, indicate "not applicable".*

If you answered yes to the above question, please elaborate. Otherwise, indicate "not applicable".*

Please elaborate on the above question, or indicate "not applicable" if you selected "No"*

If yes, please share your symptoms and what you think would be helpful to know in order to support you during this course. If no, please write N/A.*

What do you consider to be your strengths? (please list at least three)

Waiver

Participant Informed Consent and Waiver of Liability *

I acknowledge that I am voluntarily participating in Mindfulness-Based Stress Reduction. I acknowledge and understand that I am responsible for all aspects of my health and well-being. I further recognize and understand that the instructions and advice presented to me during this course are in no way intended as substitutes for medical and/or other professional counselling. If I have any health concerns that may interfere with my participation in Mindfulness-Based Stress Reduction, I understand that I should consult my healthcare provider before beginning this Mindfulness-Based Stress Reduction course. If I experience pain or difficulty that is cause for concern during or after practicing the meditations or mindful movement exercises, I understand that I should stop immediately and consult my MBSR instructor (Jan Klimas) and my healthcare provider, before continuing on with these exercises.

I recognize, understand, and assume all risks associated with my voluntary participation in Mindfulness-Based Stress Reduction and its associated mindful movements and any potential injury caused by this. Including, but not limited to, those risks that may result in personal injury and death. In giving my informed consent to participate in Mindfulness-Based Stress Reduction, I hereby release Jan Klimas from any and all claims, now or in the future, that I may have as a result of my voluntary participation in Mindfulness-Based Stress Reduction. I agree that I have read and fully understand the above statements.

By submitting your information, you're giving us permission to contact you.

Mindfulness Based Stress Reduction (MBSR)

Please fill out the following application form. All responses will be kept in the strictest confidence. Once complete, click the SEND button. Fields marked with an * are required.

Emergency Contact Phone Number*

Which of the previous MBSR information sessions have you attended (must attend at least one)?*

Please indicate when/where. Otherwise, please indicate which session you plan to attend.

Any previous meditation experience?*

How did you hear about this? (Please specify)*

Family Doctor/ Nurse Practitioner name and Phone Number*

If applicable, please describe any recent significant medical and/or psychological changes.*

Do you take any prescription medication? (If yes, please list)*

If yes to any of the above, please elaborate. If no, please write N/A*

Otherwise, indicate "not applicable"

If yes to any of the above, please elaborate. If no, please write N/A*

Otherwise, indicate "not applicable"

If yes, please describe (substance, frequency, how long you have been in recovery). If no, please write N/A*

Otherwise, indicate "not applicable"

If yes, please share your symptoms and what you think would be helpful to know in order to support you during this course. If no, please write N/A.*

Otherwise, indicate "not applicable"

What do you consider to be your strengths?

(please list at least three)

Anything else you want me to know?

Waiver

Participant Informed Consent and Waiver of Liability *

By submitting your information, you're giving us permission to contact you during the administration of the program.

Free Online Mindful Thursdays

Please fill out the following form. All responses will be kept in the strictest confidence. Once complete, click the "send" button.

Which session are you registering for?

*The session on September 10th is co-hosted with the Shoreline Counselling. https://www.shorelinecounselling.ca/

Waiver

Participant Informed Consent and Waiver of Liability *

I acknowledge that I am voluntarily participating in the Mindfulness-Based session / Mindfulness-Based Stress Reduction course. I acknowledge and understand that I am responsible for all aspects of my health and well-being. I further recognize and understand that the instructions and advice presented to me during this course are in no way intended as substitutes for medical and/or other professional counselling. If I have any health concerns that may interfere with my participation in Mindfulness-Based Stress Reduction session or course, I understand that I should consult my healthcare provider before beginning this Mindfulness-Based Stress Reduction session or course. If I experience pain or difficulty that is cause for concern during or after practicing the meditations or mindful movement exercises, I understand that I should stop immediately and consult my MBSR instructor (Jan Klimas) and my healthcare provider, before continuing on with these exercises.

I recognize, understand, and assume all risks associated with my voluntary participation in Mindfulness-Based Stress Reduction session and course and its associated mindful movements and any potential injury caused by this. Including, but not limited to, those risks that may result in personal injury and death. In giving my informed consent to participate in Mindfulness-Based Stress Reduction session or course, I hereby release Jan Klimas from any and all claims, now or in the future, that I may have as a result of my voluntary participation in Mindfulness-Based Stress Reduction session or course. I agree that I have read and fully understand the above statements.

By submitting your information, you're giving us permission to contact you.

In-person Saturday mini-retreats

Please fill out the following form. All responses will be kept in the strictest confidence. Once complete, click the "send" button.

Which session are you registering for?

Waiver

Participant Informed Consent and Waiver of Liability *

I acknowledge that I am voluntarily participating in the Mindfulness session / Mindfulness-Based Stress Reduction course. I acknowledge and understand that I am responsible for all aspects of my health and well-being. I further recognize and understand that the instructions and advice presented to me during this course are in no way intended as substitutes for medical and/or other professional counselling. If I have any health concerns that may interfere with my participation in the Mindfulness session / Stress Reduction course, I understand that I should consult my healthcare provider before beginning this Mindfulness session / Stress Reduction course. If I experience pain or difficulty that is cause for concern during or after practicing the meditations or mindful movement/yoga exercises, I understand that I should stop immediately and consult my instructors (Jan Klimas and Associates), and my healthcare provider, before continuing on with these exercises.

I recognize, understand, and assume all risks associated with my voluntary participation in Mindfulness session / Stress Reduction course and its associated mindful movements/yoga and any potential injury caused by this. Including, but not limited to, those risks that may result in personal injury and death. In giving my informed consent to participate in Mindfulness session / Stress Reduction, I hereby release Jan Klimas and his Associates from any and all claims, now or in the future, that I may have as a result of my voluntary participation in Mindfulness session / Stress Reduction course. I agree that I have read and fully understand the above statements.

By submitting your information, you're giving us permission to contact you.

Let’s connect.