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

THIS IS CONFIDENTIAL: Any information you offer here will NOT be shared and will be kept in the strict confidentiality. The purpose of this form is to ensure I am able to provide the safest and deepest possible experience for you. Feel free to keep your answers brief.

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.

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. 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:

PAYMENT OPTIONS

Sliding scale is offered based on need to those who cannot afford this course otherwise. If this is you, please select this option. If you need options beyond what is offered in the drop-down menu, please simply write me at ralph@ralphdelarosa.com.

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

PAYMENT OPTIONS

Sliding scale is offered based on need to those who cannot afford this course otherwise. If this is you, please select this option. If you need options beyond what is offered in the drop-down menu, please simply write me at ralph@ralphdelarosa.com.

No questions asked and no one turned away for lack of funds.

Sponsor rate is for those who wish to contribute a little extra to support someone who is choosing the sliding scale option.