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Mindful-Self Compassion Background Information Form

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 teacher(s). If you feel uncomfortable answering any questions, please note this below, and we can have a private conversation before the program begins. Leaving a question blank will have no impact on inclusion in the program.

Name*
Occupation
Date of birth*

DD
MM
YYYY
How do you self-identify with your gender?*
Do you identify as Aboriginal or Torres Strait Islander?
- Yes
- No
Will you be attending the program with a significant other (spouse, relative, friend)?
- Yes
- No
Please list their name(s)
Why are you interested in participating in MSC at this time?
Do you have a regular practice of meditation?
- Yes
- No
Please describe - It’s not necessary to have any experience of meditation prior to this program.
Do you have any meditation retreat experience?
- Yes
- No
Do you have any physical illness or limitation that may impact your participation in the program?
- Yes
- No
Please describe your physical illness or limitation that may impact your participation.
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, fasting).
- Yes
- No
How are you coping with them?
Are you currently seeing a therapist or counsellor?
- Yes
- No
Is your counsellor aware you are attending this retreat?
- Yes
- No
In the unlikely event of a psychological emergency, may we contact your counsellor?
- Yes
- No
Please provide their contact information:
Are you currently taking psychoactive medication, or any medication that may affect how you feel during MSC?
- Yes
- No
What medication are you taking?
Is there anything else that might be helpful for the instructors to know at this time?
- Yes
- No
Message to instructors
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. For 8 week course participants, I am planning to participate in the entire course (including the 4- hour retreat), 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.
Comments
This field is for validation purposes and should be left unchanged.

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Psychotherapy and Counselling
Mindfulness and Self-Compassion Training
About
Fees
Contact

Accredited Member Australian Association of Social Workers (Member No. 440837)
Accredited Mental Health Social Worker
Trained Teacher in Mindful Self-Compassion, Center for Mindful Self-Compassion, University of California San Diego

Medicare Provider under the Better Access to Mental Health Care Program

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