Mindful Self-Compassion Asheville Fall 2019 Registration & Background Information Form
The 8 weekly sessions will take place every Thursday evening from September 5th through October 24th from 6PM until 9PM at Le Coeur, 602A Haywood Road, upstairs from West Asheville Yoga. The 5-hour mini-retreat on Saturday, October 12th will be held from 10AM until 3PM in a beautiful rural setting close to Asheville. Food will be provided, in line with your individual dietary needs.
Please provide the following background information to help your teacher 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 instructor. If you feel uncomfortable answering any questions, please note that on the form and we can have a private conversation before the program begins. This will have no impact on your inclusion in the program. Thank you.
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First and Last Name *
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Email address *
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Mailing Address *
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City, State & Zip *
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Telephone Number *
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Occupation *
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Year of Birth
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Gender pronoun preference
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Do you identify as a person of color?
Will you be attending the program with a friend, partner, or relative? If so, please list their name(s) and their relationship(s) to you.
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 long have you been practicing? It is 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 limitation that may impact your participation in the program? If so, please elaborate.
Your answer
Are there any stressful life circumstances that might make this program difficult for you at this time? (examples may include recent loss of loved one or job, substance abuse, fasting)
Your answer
Are you currently under the care of a therapist or counselor? If so, is your care provider aware of your planned participation in this program? In the unlikely event of a psychological emergency, may we contact your counselor? If so, please provide contact information.
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Are you currently taking psychoactive medication, or any medication that may affect how you feel or think during this program? If so, please list the medication and the condition you take it for.
Your answer
Please share anything else you think might be important for your instructor to know at this time.
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Do you understand that your participation in this program is entirely voluntary and that you are free to withdraw at any time without penalty or prejudice, except for the non-refundable course fee? *
At the present time, is your intention to participate in the entire course, including the 4-hour retreat, and to practice mindful self-compassion at least 30 minutes daily (formally or informally)? *
Do you understand that you are responsible for your personal safety and wellbeing, and will you practice self-care throughout the program? *
What kind of seating would you prefer? *
How did you hear about the course? *
Your answer
Preferred payment method ($425, minus $75 discount for those registering and paying by August 22nd) *
Would you like to add a donation to the scholarship fund to help those who cannot participate in the course without financial assistance? *
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