MSC SC Registration — Kate Sheehan, LCSW

Mindful Self-Compassion Background Information Form

Please provide the following background information to help your teacher(s) 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(s). If you feel uncomfortable answering any questions, please note that on the form and we can have a private conversation before the program begins. Leaving a question blank will have no impact on inclusion in the program. Thank you.

Name

First Name

Last Name

I'm interested in the course starting...

Phone

(###)

###

####

Address

Date of Birth

YYYY

Pronouns

Occupation

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?

Do you have a regular practice of meditation/mindfulness? If so, please describe. (It’s not necessary to have any experience of meditation prior to this program.)

Do you have any physical illness or limitation 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). If so, how are you coping with them?

Are you currently seeing a therapist or counselor?

Yes

If so, is your counselor aware you are attending this retreat?

Yes

In the unlikely event of a psychological emergency, may we contact your counselor? If so, please provide contact information:

Are you currently taking 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?

How did you hear about this class?

By submitting this form, I acknowledge that 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 and to practice mindful self-compassion at least 10 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.