MSC Course Questionnaire Please fill out as completely as possible. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmailPhoneAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of BirthOccupationWhat are your personal pronouns?How did you hear about this course?Why are you interested in learning to practice Mindful Self-Compassion at this time?Are you a mental health professional planning to receive Continuing Education credit for this course?YesNoDo you have any previous experience with meditation? (Note: It is not necessary to have meditation experience to take this course.)YesNoIf yes, tell us briefly about your meditation background?Please share any particular life circumstances that might be causing you extra stress at this time? (Examples might include: recent job loss, death of a loved one, medical diagnosis, recovery journey, etc.)Are you currently seeing a therapist or counselor?YesNoIf yes, is your counselor aware you are taking this MSC course?YesNoIn the unlikely event of a psychological emergency, may we contact your counselor?YesNoCounselor name and contact information:Please share anything else it might be helpful for your MSC instructor to know about you?In case of emergency, the following person should be contacted.Emergency Contact NameFirstLastEmergency Contact Relationship to YouEmergency Contact PhoneEmergency Contact EmailSubmit