MSC registration — Sally Harris Mindfulness

Please provide the following background information to help Sally assess if MSC will be helpful to you at this time and to support you during the programme. This information will only be read by Sally.

If you feel uncomfortable answering any questions, please note that on the form and we can have a private conversation before the course begins. Thank you.

Name *

First Name

Last Name

Email *

Phone number *

Which MSC course are you hoping to join? *

Why are you interested in participating in MSC at this time? *

Do you have a regular practice of meditation? If so, what type and how many years have you been practising? *

It’s not necessary to have any experience of meditation prior to this course.

Do you have any physical illness or limitation that may impact your participation in the course? *

Yes

If yes, please describe below

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, moving house)

Are you currently seeing a therapist or counsellor? *

Yes

If so, is your counsellor aware you are attending this course?

Yes

N/A

In the unlikely event of a psychological emergency, may we contact your counsellor? If so, please provide contact information: *

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

Emergency contact person name *

First Name

Last Name

Their relationship to you *

Emergency contact person phone number *

How did you hear about this course?

Tick all that apply

Sally's newsletter

Sally's Facebook page

Sally's Instagram

Word of mouth

Google search

Oxford Daily Information website

Mindful Self-Compassion UK website

Mindful Directory website

Poster

Flyer through my door

Other

Thank you!

By clicking submit I confirm that I understand that my participation in this course is entirely voluntary and I am free to withdraw at any time. At the present time, I am planning to participate in the entire course, and to practice mindful self-compassion for around 30 minutes a day (formally or informally). I also understand that I am responsible for my personal safety and wellbeing and will practice self-care throughout the course.

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