MSC Course Questionnaire

Please fill out as completely as possible.

Name *

First

Last

Email

Phone

Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Date of Birth

Occupation

What 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?

• Yes
• No

Do you have any previous experience with meditation? (Note: It is not necessary to have meditation experience to take this course.)

• Yes
• No

If 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?

• Yes
• No

If yes, is your counselor aware you are taking this MSC course?

• Yes
• No

In the unlikely event of a psychological emergency, may we contact your counselor?

• Yes
• No

Counselor 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 Name

First

Last

Emergency Contact Relationship to You

Emergency Contact Phone

Emergency Contact Email

Submit