C O U R S E E N R O L L M E N T

Name

First Name

Last Name

Email Address

What inspires you to take this course?

What, if any, is your history with meditation practice?

During this course, difficult emotions and memories might come up. Though you will be given tools to work with this and encouraged to always move at your own pace, I want to make sure you are safe and that this course speaks specifically to what you're working with. The following information will be kept strictly confidential. Feel free to keep your answers short.

What psychological and/or behavioral issues are you facing now or wanting to work on?

Do you have any history of emotional instability or psychiatric hospitalizations? Please explain.

Are you currently in psychotherapy or taking psychoactive medications? For how long?

If you were in emotional difficulty or felt like you were falling apart, where would you turn?

Please read the disclosure below and type your initials if you agree with these terms.

I understand that Ralph's online courses are not psychotherapy. Even though they teach psychotherapeutic methodologies, they are intended to teach me skills I can use for my personal growth. They may involve accessing sensitive psychological material, and I declare that I have the psychological stability to handle whatever may come up. I am responsible for my participation in the class and any psychological work that I choose to do, and I will not hold Ralph De La Rosa responsible for any pain or damages that may occur.

Please type your name in place of your signature:

PLEASE READ: This course asks that you commit to the full journey. You cannot sign up for just one phase of it. This is to aid in the creation of a solid container for this deep work. Some of you may be tentative or find the commitment challenging — an understandable managerial defense against the vulnerability that lies ahead. This is a major theme of the first series — that is, this course will be an opportunity to address the resistance to healing and growth that is impacting every arena of your life.

Furthermore, students empower the teacher. Your commitment on all levels — energetic, emotional, physically showing up, and the financial exchange — are what gives me the energy and psychic space to hold the container for the group, deliver the material, and so forth. If for some reason you must drop out of the course part way through, I will navigate that matter with you individually towards a fair and generous resolve.

C O U R S E E N R O L L M E N T

A minimum of 10 students is required for this course to take place.Thank you.

A minimum of 10 students is required for this course to take place.

Thank you.