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

Any information you offer here is confidential and will NOT be shared with anyone ever.

The purpose of this form is to ensure I am able to provide the safest and deepest possible experience for you.

Name

First Name

Last Name

Email Address

Emergency contact

Name and phone number of an emergency contact

What inspires you to take this course?

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

Though this course focuses on healing, it is simply the nature of self-work and meditations that 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 aware that there are risks you alone are responsible for. The following information will be kept strictly confidential and will never be used to stigmatize or judge you. Feel free to keep your answers short.

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

If you were in emotional crisis 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. 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.

Please type your name in place of your signature: