Register for Mindful Self-Compassion

Please use the following form to register for our Mindful Self Compassion class.

Thursday evenings 6:15pm-8:45pm
OR
Thursday mornings (for mental health providers) 10:00am-12:30pm
January 9 - February 27th, 2020

1/2 day retreat Sunday, February 16th, 2020 8:30am-12:30pm
Atlanta Center For Wellness Suite 450

Please note: 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 or simply leave it blank. Leaving a question blank will have no impact on inclusion in the program. Thank you.


                        Name*
                            
                            
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Email*
                            
                        
Address*    
                    
                         
                                        Street Address
                                        
                                   
                                        Address Line 2
                                        
                                    
                                    City
                                    
                                 
                                        State
                                        
                                      
                                    ZIP Code
                                    
                                
                    
                
Home Phone*Enter your cell phone if you do not have a home phone
Cell Phone
Work Phone
Choose Class Time*Thursdays, January 9 - February 27th, 2020
Date of Birth
                            
                            MM slash DD slash YYYY
                        
                        
Partnership Status
Education
Why are you interested in participating in this program?Please be advised that MSC is 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?Please note that it is not necessary to have any experience of meditation prior to this program.
How would you describe your physical health?
Are you currently in psychotherapy?Please consider providing the name and number of your therapist if you think that might be helpful.
Are you currently taking psychotropic medication, or any medication that may affect how you feel from one week to the next?If so, please provide details.
If there anything else that might be helpful for the instrutors 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, however, I am planning to participate in the entire course (including the retreat), and to practice mindful self-compassion up to 30 min/day (formally or informally).*
								
								I Agree