Registration Form

Mindful Self-Compassion Program : Oct –Dec 2020

Please fill out the application form below. This confidential information will only be used to ensure you can realise the full benefits from your participation in the training. If you feel uncomfortable answering any questions, please note that on the form and you can discuss this privately before the program begins.

Name

Email Address

Name preferred for name tag

Address

Telephone (Mobile)

Date of Birth

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

Occupation

Emergency contact name and number and relationship to you

How did you find out about this training?

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

Have you done any forms of meditation before? If so, what kind, and was it helpful? (Please note, no previous meditation experience is required for our course)

If you have a regular practice how many years and what type have you been practicing?

Are there any health or mobility concerns that we should know about or you would like to tell us about?

Are you currently seeing a therapist or counselor? Are you currently seeing a therapist or counselor? Yes No

Is your counselor aware you are attending this retreat? Is your counselor aware you are attending this retreat? Yes No Not Applicable

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

Have you been diagnosed with a serious mental health illness? Have you been diagnosed with a serious mental health illness? Yes No

Is there anything else that would be helpful for you teacher 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 and I understand that the course fee is not refundable. At the present time, I am planning to participate in the entire course (including the 4 hour retreat) and to practice mindful self-compassion for approximately 30 minutes a day (formally and informally). I also understand that I am responsible for my personal safety and well being and will practice self-care throughout the program. I understand that my participation in this program is entirely voluntary and I am free to withdraw at any time and I understand that the course fee is not refundable. At the present time, I am planning to participate in the entire course (including the 4 hour retreat) and to practice mindful self-compassion for approximately 30 minutes a day (formally and informally). I also understand that I am responsible for my personal safety and well being and will practice self-care throughout the program. Agree

Registration Form

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