Background Information

Please read the course information on the Home and Course pages before submitting this form. If you have any questions, please get in touch via the Contact page. (There are links on both the Course and Contact pages that will bring you back here when you're ready.) Thank you.

Please note: This information will only be read by the course instructors, in complete confidence. If you feel uncomfortable answering any of the questions, you can simply note that on the form; we can have a private conversation before the program begins if that would be helpful. Leaving a question blank will have no impact on inclusion in the program.

Name *
Name
Home address
Home address
Home phone
Home phone
Cell phone
Cell phone
Date of birth
Date of birth
Partnership status
Education
How would you describe your physical health?
I understand that my participation in this program is entirely voluntary, and that 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 at least 30 minutes a day (formally or informally). *
I understand that my participation in this program is entirely voluntary, and that 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 at least 30 minutes a day (formally or informally).
Today's date *
Today's date