MSC Participant Background Survey
Please provide the following background information to help your teacher(s) assess if MSC will be helpful to you at this time and to support you during the program. This information will only be read by the course instructors. If you feel uncomfortable answering any questions, please note that on the form and we can have a private conversation before the program begins. Leaving a question blank will have no impact on inclusion in the program. Thank you!

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Email *
Name *
Phone Number *
Date of Birth
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YYYY
How do you self-identify your gender?
Will you be attending the program with a significant other (spouse, relative, friend)? If so, please list the name/names:
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’s not necessary to have any experience of meditation prior to this program.
Do you have any physical illness or limitation that may 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 loved one or job, substance use)?
Are you currently seeing a therapist or counselor?
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If so, is your therapist/counselor aware you are attending this class?
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In the unlikely event of a psychological emergency, may we contact your counselor? If so, please provide contact information:

Are you currently taking psychoactive medication, or any medication that may affect how you feel during MSC? If so, please provide details.
Is there anything else that might be helpful for the instructors to know at this time?

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 15 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. **Please type name to sign** *
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