FALL 2024 Wednesday
Mindful Self Compassion
Registration

September 11 through November 6
starting 9 AM PT / 12 noon ET / 18:00 CET-SAST
Time Zone Converter

Four Hour Retreat on Saturday October 19
More information at the start of the program.

This form does not have an automatic payment attached because we already received payment. We would like to reiterate, though, that we operate on a gift-giving basis. Towards the end of the program we will ask you to consider a donation to Imagine. This video on our Donations page explains our philosophy. You will also receive more information during the Information Session.

First Name

Last Name

Email Address

International Phone Number

City and Country (International Sign Ups) OR City and State (US Sign Ups only)

How did you hear about this Live Online Mindful Self Compassion Program?

Year of Birth

Emergency Contact Name and Phone Number

How do you self-identify your gender?

Why are you interested in participating in MSC at this time? Please be advised that MSC is primarily designed for personal growth and development.

Do you have a regular practice of meditation? If so, what type and how many years have you been practicing? It is NOT necessary to have any experience of meditation prior to this program.

Do you have any physical illness or limitations that might impact your participation in the program? If yes, 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 love one, or loss of a job, substance use, fasting ...)

Are you currently seeing a therapist or counselor? If Yes, are they aware that you are attending this course? In the unlikely event of a psychological emergency, may we contact your counselor? If yes, please provide their contact information.

Are you currently taking psychoactive medication, or any medication that may affect how you feel during MSC? If yes, please provide details.

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

I have read and understand that sessions might be recorded..

I have read and understand the confidentiality clause.

I have read and understand the participation clause.

I hereby acknowledge that I have read and agree with the terms set out in the MSC Waiver posted below. (Click the link to read the Waiver.)

MSC Waiver

Your name

Today's date

Thank you for your registration! You will receive an email with details. Please proceed to your payment.