Mindfulness/Well-being Program Application

Background Information

1. Your contact information:

First name: *This question is required.

Last name: *This question is required.

Your email: *This question is required. This question requires a valid email address.

Your pronouns:

2. Which PEPS Groups have you facilitated? (please check all that apply): 

Expectant Parents
Newborn
Second Time Around
Baby Peppers (babies 5-12 months)
Parents of Adolescents and Teens (PAT)
Affinity (Single Parents, LGBTQIA+, Working Moms, International Families, Military Families)

3. If you have children, how many and what are their ages? 

4. Please share your interest in participating in this program. What do you hope to learn?

5. Do you have any previous experience with contemplative practices that you wish to share? 

6. Some of the sessions will incorporate very short yoga sequences that can be done standing up and/or in a chair.
Please let us know if you have any physical considerations for mindful movement based-practices. 

7. Is there anything else you would like the facilitator to know before you sign up? 

8. Please note that this program is not intended to treat mental health challenges or substance misuse. Please check the box: *This question is required.

I confirm that I understand this program is not a replacement for diagnosis or treatment of mental health or substance use conditions.