Mindful Self-Compassion Background Information Form

"*" indicates required fields

Name*

First Last

The year you were born*

Do you use personal gender pronouns ...PGPs?

Yes

What are your personal pronouns?*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email Address*

Email Address Confirm Email Address

How did you find about the Mindful Self-Compassion Program?*

Will you be attending with someone you know?

Do you have a Mental Health Therapist or Counselor?*

Yes

No

Are they aware of you attending the MBSR Program?*

Yes

No

Why are you interested in participating in the Program at this time?*

Please briefly describe any prior experience with self-compassion that you may have

Please briefly describe any prior experience with meditation that you may have:

Are there any life circumstances that might make this program more challenging at this time?*

Is there anything else that might be helpful for the instructors to know at this time?

Include Your Payment*

Yes

No, I have already paid

Mindful Self-Compassion Payment

Mindful Self-Compassion - $275

Total

Credit Card

Cardholder Name

Card Details

Captcha

Email

This field is for validation purposes and should be left unchanged.