REGISTRATION: 8 Week Mindful Self-Compassion ONLINE PROGRAM: March 22 – May 17, 2021

Name: *

First

Last

Email: *

Address:

Street Address City Province / State Postal / Zip Code

Phone:

Date of Birth:

day

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month

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year

Occupation:

Emergency Contact Name & Phone Number:

Family Doctor Name & Phone Number:

How do you self-identify your gender?

Will you be attending the program with a significant other (spouse, relative, friend)? If so, please list their name/names:

How did you hear about this program?:

Why are you interested in participating in MSC at this time? Please be advised that MSC is primarily designed for personal growth and development.

Do you have a regular practice of meditation? If so, what type and how many years have you been practicing? (NOTE: It’s not necessary to have any experience of meditation prior to this program).

Do you have any meditation silent retreat experience?

Do you have any physical illness or limitation that may impact your participation in the program?

Yes

No

If yes, please describe.

Do you have any current mental health challenges that may impact your participation in the program?

Yes

No

If yes, please describe.

Have you experienced events you would consider traumatic, or suffered abuse in the past?

Yes

No

If yes, please consider speaking directly to the one of the course facilitators prior to the program if you feel that these experiences may impact your ability to participate in this program.

Are you currently abusing alcohol or drugs?

Yes

No

Do you have a history of abusing alcohol or drugs?

Yes

No

If yes, how long have you been in recovery and do you participate in a recovery support program of some sort?

Are there any stressful life circumstances that might make this program difficult for you at this time (e.g., recent loss of a loved one or job, fasting).

Do you currently have an individual therapist, psychiatrist or any other person helping you with mental or emotional health concerns?

Yes

No

If yes, is your counselor aware you are attending this program?

Yes

No

If yes, please provide their name and contact information:

In the unlikely event of a psychological emergency, may we contact your counselor?

Yes

No

Are you currently taking psychoactive medication, or any medication that may affect how you feel during MSC? If so, please provide details

Is there anything else that might be helpful for the facilitators to know at this time?

I understand that my participation in this program is entirely voluntary and I am free to withdraw at any time. At the present time, I am planning to participate in the entire program (including the 3-hour retreat), and to practice mindful self-compassion at least 30 min/day (formally or informally). I also understand that I am responsible for my personal safety and wellbeing and will practice self-care throughout the program.

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