Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday *

MM

DD

YYYY

Session I would like to attend:

Evening Sessions

Lunchtime Sessions

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 this time, I am committing to participate in the full 4-week course. I understand that this class is not designed as medical or counseling treatment and does not replace medical treatment by licensed healthcare providers. I understand that to receive the full benefit of this class, I must practice at home. I understand participating in this class does not begin a client/therapist relationship.

Yes, I fully agree!

No, I have questions. Please contact me.

Please know that mindfulness can bring up strong emotional reactions or physical responses. If you feel you may be activated by a new mindfulness practice due to your trauma history or any other circumstances, please speak with your facilitator and/or therapist prior to signing up.

I understand, and will speak to my therapist and/or this course facilitator prior to beginning this course.

I do not understand. I need to discuss this with you prior to signing. up.