Mindfulness for Primary Infertility Registration

Place of residence (what province/ state/ country will you be logging in from?)*

This informs us which time zone applies to you.

Name*

First Last

Best phone number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Confirm Email*

Emergency contact name & phone number*

Primary care physician or therapist name & phone number*

How did you hear about this course? We would love as much specific detail as possible (eg. online search, Instagram feed, Facebook group, friend, name of healthcare practitioner referral, etc)*

Which of the following best describes your situation?*

Please tell us a little about yourself, your fertility journey, and what brings you to this class at this time.*

Please check the box(es) that apply to you:*

Briefly describe any major stressors, worries or concerns in your life.*

What are three ways you hope to benefit from this course?*

Do you have anxiety or depression, suicidal episodes, post-traumatic stress, borderline personality disorder or active drug/alcohol dependency? If so, please describe and list any supports you have worked with in the past or are currently engaged with now.*

Are there any health conditions that are a concern for you? Or may interfere with your ability to fully participate in the course? If yes, please describe and share what adaptations you might need.*

On a scale from 1 to 10 how certain do you feel that you can commit to approximately 45min minutes of daily practice, 5-6 days a week while you are in the program? Please select a number.*

** Please take a moment to mark all sessions in your calendar. ** Are there any dates you know in advance you will miss class?*

NO - I can attend all sessions
YES – I will be missing a class(s)

Please list date(s) with conflicts:

Consent & Waiver*

I understand that this Mindfulness for Fertility (MFF) Program includes skill training in meditation techniques. I understand that if for any reason I am unable to, or think it unwise to engage in these techniques and exercises either during the weekly classes or at home, I am under no obligation to participate in them. I understand that I am committing to attend each of the six (6) weekly sessions, and to practice the home assignments during the duration of the training program. This agreement releases the instructors (Stephanie Curran & Alda Ngo) from any liability relating to potential injuries that may occur due to participation in the Program. I also acknowledge the risks involved in the MFF Program.These may include but are not limited to physical injury and emotional distress. I swear that I am participating voluntarily. I will also make every effort to observe safety precautions as listed in writing and as explained to me verbally. I will ask for clarification when needed.

I fully understand and agree to the above terms.

Deposit

A $100 deposit to reserve your spot in the program can be paid securely via Visa/Master Card or through a PayPal account. Please note this deposit is non-refundable after the course begins. Please select your payment method below to complete your transaction. The remainder of your sliding scale fee can be paid at the completion of the 8 week program.

Deposit

Price:

Payment Method

MasterCard

Visa

Card Number Card Number Expiration Date Expiration Date Security Code Security Code Cardholder Name

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Mindfulness for Fertility

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Mindfulness for Fertility Intake Form

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