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 address *
Course Location & Dates
Tuesday evenings 6:15-9pm at 2808-II East Madison St. Suite 206, Seattle, WA 98112

March 3
March 10
March 17
March 24
March 31
April 7
(April 14th there won't be class)
April 21
April 28

There will be a required half-day retreat on April 4th (4 hours). Location TBD

First Name *
Your answer
Last Name *
Your answer
Phone number *
Your answer
Mailing address *
Your answer
Occupation *
Your answer
Date of Birth *
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DD
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YYYY
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: *
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? It’s not necessary to have any experience of meditation prior to this program. *
Your answer
Do you have any meditation retreat experience? *
Your answer
Do you have any physical illness or limitations that may impact your participation in the program? If so, 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 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:
Your answer
Are you currently taking psychoactive medication, or any medication that may affect how you feel during MSC? If so, please provide details. *
Your answer
How did you find out about this course? *
Your answer
Is there anything else that might be helpful for the instructors to know at this time? *
Your answer
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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