MSC Participant Background Survey
For the Full 8 Week Mindful Self-Compassion Course,
Feb 2 -April 5, 2019 at Be Well Austin
with Krista McGregory and Katherine Winge

Please provide the following background information to help your teacher(s) assess if MSC will be helpful to you at this time and to support you during the program. This information will only be read by the course instructors. If you feel uncomfortable answering any questions, please note that on the form and we can have a private conversation before the program begins. Leaving a question blank will have no impact on inclusion in the program.
Thank you.
Email address *
Name *
Your answer
Occupation
Your answer
Date of birth
MM
/
DD
/
YYYY
How do you self-identify your gender? *
Will you be attending the program with a significant other (spouse, relative, friend)? If so, please list the name/names: *
Your answer
Why are you interested in participating in MSC at this time? Please be advised that MSC is primarily designed for personal growth and development. *
Your answer
Do you have a regular practice of meditation? If so, what type and how many years have you been practicing? **Please know that it’s not necessary to have any experience of meditation prior to this program. *
Your answer
Do you have any physical illness or limitation that may impact your participation in the program? Please write "Yes" or "No". If "yes" please describe. *
Your answer
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, substance use, fasting). *
Your answer
Are you currently seeing a therapist or counselor? *
If so, is your counselor aware you are attending this course?
Is there anything else that might be helpful for the instructors to know at this time?
Your answer
I understand that my participation in this program is entirely voluntary and I am free to withdraw at any time without penalty or prejudice, except for the non-refundable course fee. At the present time, I am planning to participate in the entire course (including the 4-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. Please type your name and date below if you agree. *
Your answer
Thank you for filling out this survey! If you have any questions please email Katherine at katherineheartsyoga@gmail.com or Krista Gregory at Gregory.krista@gmail.com.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service