Welcome! We’re glad you’re interested in taking the Mindful Self-Compassion 8-week course. To register, please fill out your information in the form below. About you:Your name* First Last How did you hear about this course? Please be as specific as you can.*Your profession*Therapist, stay-at-home parent, physician, teacher, attorney, coach, etc.Are you a KS or MO licensed mental health professional who is interested in earning continuing education credit for this course?*Note that this course is appropriate for laypeople and professionals alike. No prior training is required for this course.Yes, I would like to receive CEs.No, I don't wish to receive CEs.How may we contact you?Phone*Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Background informationWhy are you interested in participating in this program?*Please note that MSC is designed for personal growth and development; it is not a replacement for therapy. While meditation isn't a prerequisite for this program, it helps us to know if you have experience with meditation. If you have a regular practice of meditation, what type and how many years have you been practicing?*How would you describe your physical health?* Excellent Good Fair Poor Are you currently in psychotherapy?*If you are in psychotherapy, please share a bit about your current therapeutic goals.Are you currently taking psychoactive medication, or any medication that may affect how you feel from one week to the next?*In the past 6 months, have you had any thoughts of harming yourself or someone else?*If there is anything else that would be helpful for the teachers to know, please let us know below.*Course fees and registrationDo you wish to apply for financial support?*It is our intention to make the course available to as many people as possible. Given the large number of participants requesting support, we request both additional information (below) and mindful consideration of what is true, kind, and wise for you, for the teachers (who personally finance any discount you may receive), and your fellow classmates.NoYesFor those requesting financial support, please list below your annual average annual household income for the past 2 years, the number of people in your household, and any mitigating circumstances.**Mitigating circumstances could include costly legal procedures, extended unemployment, family illness or death, working/volunteering in an extremely underserved area, etc.I am requesting the following discount:*10% discount20% discount30% discount40% discount50% discountMSC 8-week course deposit pending financial aid decision*Your deposit holds your spot until an agreement has been made about financial support. Any remaining course fee will be payable 2 weeks prior to the course start date. Price: $125.00 Mindful Self-Compassion 8-week course and retreat* Price: $645.00 Total due $0.00 AgreementsCancellationsCancellations up to two weeks before the course start date are subject to a 50% fee. No refund is provided after that point.I agreeI disagreeWaiver*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, however, I am planning to participate in the entire course (including the retreat), and to practice mindful self-compassion at least 30 min/day (formally or informally). I agree I do not agree CommentsThis field is for validation purposes and should be left unchanged. Share this:Click to share on Facebook (Opens in new window)Click to share on Google+ (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Twitter (Opens in new window)Click to share on Pinterest (Opens in new window)