Registration Form Please note Kathleen is currently not available for new clients for individual psychotherapy. I am registering my interest for:*8 week MSC course - 2017new client registrationName* First Last Preferred name for name tag*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Date of Birth*AgeGenderFemaleMaleOtherOccupation*EducationHigh SchoolCollegeGraduateOtherEmergency Contact Name and Number and Relationship to you*How did you find out about this training/ our services?*What are you hoping to get out of training / therapy?Have you done any forms of meditation before? If so, what kind, and was it helpful? (Please note, no previous meditation experience is required for our course)If you have a regular practice how many years and what type have you been practicing?How would you describe your physical health:* Excellent Good Fair Poor Please let us know if you have any problems with mobility, so that we can ensure that you are as physically comfortable as possible. (Note, our venue is wheel chair friendly and we provide chairs to sit on).Do you have any special dietary requirements?Are you currently seeing a psychologist/ psychiatrist / counsellor* Yes No If Yes, please provide the name and telephone number of your TherapistNote: We would not contact your mental health professional unless you had given your consent beforehand.Are you currently taking psychoactive medication, or any other medication that may affect how you feel from one week to the next?* No Yes If Yes, please provide details:Have you been diagnosed with a serious mental health illness or experienced trauma in your life?* No Yes Note. If so, this will not necessarily preclude you from participating in the course. It will prompt our teachers to discuss with you whether this course is appropriate for you at this time, given your individual circumstances. If the course is considered suitable and is supported by the teacher, then prior to commencement one of the teachers will have a conversation with you to form a self-care plan, which will aim to help you manage any symptoms should they arise during the training. Is there anything else that would be helpful for your teacher/ psychologist to know at this time?Thank you for sharing your personal information. Prior to beginning your course, your teacher will also conduct a brief telephone interview (10-15 minutes) over the phone. Please nominate three most convenient times/days for your teacher to call you (We are available to call you after-hours or on weekends).After the telephone interview, you will receive an invoice from Metta Health & Psychology. Please note that places in all our programs are limited and are likely to fill to capacity. It is highly recommended that you pay your deposit early to secure your place. With Loving Kindness.