Name
*
First Name
Last Name
Email Address
*
Emergency Contact
*
What inspires you to take this course?
*
What, if any, is your history with meditation practice?
*
IMPORTANT: During this course, difficult emotions and memories are likely to come up. Though you will be given tools to work with this and encouraged to always move at your own pace - and even skip sessions that might be too much for you. It is encouraged that you be in weekly psychotherapy and/or have strong supports in your life. If you have a history of severe mental illness, psychiatric hospitalizations, suicide attempts or gestures, being in the care of a therapist is very strongly suggested. I want to make sure you are safe and supported in doing this important work. Please TYPE "YES" below to acknowledge you have read this.
*
What psychological and/or behavioral issues are you facing now or wanting to work on?
*
Do you have any history of emotional instability, self-harm, suicide attempts, 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?
*
Are you currently seeing a licensed psychotherapist?
*
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. I understand that the practices in this course can elicit difficult and painful emotional material and that the nature of Ralph's course is to offer me skills to relate to that material directly instead of avoiding it. 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.