Name
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First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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Email
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Date of Birth
Gender
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?
If you have any physical illness or limitation that may impact your participation in the program, 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 therapist or counselor?
If so, is your counselor aware you are attending this
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.
Is there anything else that might be helpful for the instructors 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 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).
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WAIVER OF LIABILITY: I voluntarily agree to participate in activities of the 8-week MSC program. I hereby assume all risks of injury to me and my property that may be sustained in connection with activities undertaken during the program. I understand that the teachers are not expected or able to provide medical and/or psychological care. I agree that, in the event a teacher determines that I need professional medical or psychological attention, the teacher has the authority and sole discretion to contact 911 emergency services, as well as the designated emergency contact person listed. Any costs incurred for health services are my responsibility and not the responsibility of the teacher or the course facility. • I understand that I must provide the name and contact details of an emergency contact person in order to attend MSC. The teachers and facility staff will make every effort to communicate with this person in the event of an emergency. This person is someone who can either collect me from the facility or help to make transportation arrangements if I need to leave the retreat early. I further understand that participation in MSC is at the discretion of the teachers at all times. If, in the opinion of the teachers, I am unable to continue to participate productively in the course, I may be asked to leave. If I am taking prescription medications of any kind and discontinue taking them during the program, this may be grounds to be asked to leave. I understand that MSC is a compassion skills training program, not group therapy. MSC is designed to teach participants the tools needed to develop and cultivate a mindfulness and self-compassion practice. I understand that MSC does not take the place of personal therapy. • By completing this release and consent I assume all risk for any physical, mental and/or emotional consequences of participating in this process/program. By signing this release and consent I also specifically and expressly agree to hold harmless, indemnify and release all facilitators and teachers of this program and/or facility from any and all liability for the results of the educational guidance that will be or have been provided. I understand that no guarantee is made as to the outcomes or results of this educational training program. I understand that while this program may have therapeutic benefits, it is not psychotherapy or a substitute for psychotherapy. Some or all of the facilitators of this program may be credentialed psychotherapists (e.g., clinical social workers, psychologists, marriage and family therapists, psychiatrists, etc.) but their role in this program is strictly as facilitators and teachers and not as psychotherapists. Thus, any interactions between myself and the facilitators should not be construed as being psychotherapy and do not imply a clinical relationship between us. I agree that if I am in need of psychotherapeutic support or intervention, I will seek it through appropriate channels including, but not limited to, asking for referrals from the program facilitators.
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