Mindful Self-Compassion (MSC) Background Form
Please provide the following background information to help your teacher(s) assess if the MSC course will be helpful to you at this time and to determine how 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 at the end of the form and we can have a private conversation before the program begins.

Thank you!
Email *
Course Location & Dates
This online Mindful Self-Compassion course will be taught on Zoom on Thursdays at 3:30pm-6pm PT/6:30-9pm ET

March 25
April 1
April 8
April 15
April 22
April 29
May 6
May 13

There will also be a half-day online retreat (4 hours long) on Saturday, April 24th
First Name *
Last Name *
Phone number *
Mailing address *
Occupation *
Date of Birth *
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What are your preferred gender pronouns? *
Will you be attending the program with a significant other (spouse, relative, friend)? If so, please list the name/names: *
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? It’s not necessary to have any experience of meditation prior to this program. *
Do you have any meditation retreat experience? *
Do you have any physical illness or limitations that may impact your participation in the program? If so, please describe *
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). *
Are you currently seeing a counselor or therapist? *
If so, is your counselor aware you will be attending this course? *
In the unlikely event of a psychological emergency, may we contact your counselor? If so, please provide contact information:
Are you currently taking psychoactive medication, or any medication that may affect how you feel during MSC? If so, please provide details. *
How did you find out about this course? *
Is there anything else that might be helpful for the instructors to know at this time? *
Please read the following terms and accept below
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.
By selecting "I agree' you are agreeing to the terms above and submitting your course registration *
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