FA-26 MSC Reg Questionnaire | Imagine Mindfulness

Mindful Self Compassion Questionnaire

Fall 2026

Fridays October 23 through December 18

(no class on November 26) Eight 2 1/2 hour sessions

starting 9 am PT / 12 noon ET / 6 PM CET and SAST / 9:30 pm IT

Instructor Ela Compton

Please fill out this registration questionnaire. Your answers will allow me to get to know you a little before we begin.

First and Last Name

Emergency Contact Name and Phone Number

Year of Birth

How did you hear about this Mindful Self Compassion Course?

How do you self-identify your gender?

SUPPORT INFORMATION

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 meditation experience prior to this course.)

Do you have any physical illness or limitations that might impact your participation in the course. If yes, please describe.

Are there any stressful life circumstances that might make this course difficult for you at this time? (For instance, recent loss of a loved one, 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 instructor(s) to know at this time?

RECORDING OF SESSIONS

I am aware the sessions might be recorded for training purposes exclusively (to be viewed by a mentor) and no part of the recording will ever become public in any shape or form.

I have read and understand that sessions might be recorded.

CONFIDENTIALITY

All forms and discussions are confidential unless threat or harm to oneself or to others presents itself.

I have read and understand the confidentiality clause.

PARTICIPATION

I understand that my participation in this program is entirely voluntary and I am free to withdraw at any time without penalty or prejudice, except for the non-refundable course fee. At the present time, I am planning to participate in the entire course and to practice mindful self-compassion at least 30 min/day (formally or informally). I also understand that I am responsible for my personal safety and wellbeing and will practice self care throughout the program.

I have read and understand the participation clause.