MBSR Enrollment Form - Community for Deepening Practice

This enrollment form is for people who are requesting alternate payment arrangements for the MBSR class beginning Sept. 2023. No money is due at this time, and upon receipt of your enrollment form, Linda Elsby will be in touch with you via email to discuss your specific situation.

Step 1 of 4

Enrolee Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
We will use this for all course communications.
Phone
Your pronouns
ex: they/them, she/her, etc.
Occupation
If you have any specific identities you'd like us to know about, please list here.

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Mindfulness in your life
Please list any previous mindfulness trainings you have experienced, ie Mindfulness Based Stress Reduction (8 week or 5 day intensive), MBCT, Unified Mindfulness, Mindfulness Daily, etc, or N/A - not applicable.*
Why are you interested in participating in MBSR? Why now?*
Please note that this course is designed for personal growth and development; it is not a replacement for therapy
Can you please tell us a bit about your your relationship with mindfulness?*
If you are new to formal mindfulness practice, that's helpful to know, too. 🙂
As we become more attuned to our inner landscape, it is common for difficult emotions to arise. Please indicate the supports you have in place for yourself regarding this.*
Please consider both personal and professional supports ie. a supportive partner, friend, or community, and medical professionals, family doctors, specialists etc or a registered psychologist or therapist. MBSR has been designed as an adjunct to whatever professional treatments you are receiving. Although therapeutic, MBSR is not a therapy. Often referred to as participatory medicine it empowers us to participate fully in our healing in collaboration with other professionals.
If you have any special learning needs for which you request accommodation, please share those needs here.
Is there anything else that would be helpful for the teachers to know at this time?
How did you hear about this MBSR course? Please be as specific as possible.*

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Agreements
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.
- I agree.
- I do not agree.
Confidentiality*
Participants in MBSR agree to maintain the confidentiality of the other participants. Toward that end, participants should not discuss the personal material shared by anyone in a live session with individuals outside the group, or divulge the names or other details of participants that could lead to someone identifying a particular individual.
- I agree to the above confidentiality terms
- I do not agree to the above confidentiality terms
I understand that a reliable internet connection and computer are required for participation in this course. We will be using Zoom.*
While we understand that technical issues will sometimes arise, your completion of the course will be dependent on regular attendance at online meetings. If a reliable internet connection will not be available to you, we request that you reconsider your attendance at this time.
- I have a reliable internet connection.
- I do not have a reliable internet connection.
Emotional Well-being Support*
Work done in MBSR can be activating, and so we require each participant to have ongoing support available for the duration of the course. This could include a therapist, a trusted mentor or coach, etc.
- Yes, I agree to have emotional well-being support available for the duration of the course.
- No, I do not agree.
Waiver of Liability
By electronically signing below, I indicate my understanding and agreement with the following points:
- Mindfulness Based Stress Reduction (MBSR) is a group educational program for personal use, not group therapy. It is not a substitute for medical treatment or therapy by a healthcare provider.
- I understand that the teachers are not expected or able to provide medical and/or psychological care.
- Participation in a stress management course may intensify the awareness of pre-existing conditions or activate hidden memories. I understand the importance of a supportive environment outside of class while participating in this course.The instructors may out of a sense of care, inquire about details of my support system and may encourage me to reach our for support. It is my responsibility to contact my supports should difficult emotions arise.
- The CDP acts in the best interest of the course participants and course experience as a whole. If, in the opinion of the teacher(s), I am unable to continue to participate productively in the course, I may be asked to pause or withdraw.
- I voluntarily agree to participate in MBSR. I can choose to withdraw without any penalty, and I am aware that the course fee is non-refundable.
- I understand that if I am intoxicated with alcohol and/or non prescribed/prescribed drugs then I am not permitted to take part in MBSR.
- Any costs incurred for health services are my responsibility and not the responsibility of the teachers or the CDP.
- I hereby assume all responsibility for my own equipment required to attend the online sessions.
By signing below, I confirm that I have read and agree with all sections of the preceding Waiver of Liability. I also agree that I am of legal age.
Signature

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Check Out
As you are requesting a reduction in the course fee and/or an alternate payment arrangement, please note specifically how much you are able to pay and the payment terms you wish to request.*
Ex: "I am able to pay $100 per month for 3 months, totaling $300"
Please share the mitigating circumstances that are leading to your request.
Email
This field is for validation purposes and should be left unchanged.

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This enrollment form is for people who are requesting alternate payment arrangements for the MBSR class beginning Sept. 2023. No money is due at this time, and upon receipt of your enrollment form, Linda Elsby will be in touch with you via email to discuss your specific situation.

Step 1 of 4

Enrolee Information

Mindfulness in your life

Agreements

Waiver of Liability

Check Out