Shifting Self-Talk Tuesday Offering

Still River Travels

Individual Journey Course Registration
I am registering to take...
If you are registering for more than one course, please indicate which ones.
Options: Decreasing Stress, Shifting Self-Talk, Reframing Challenges, Core Values
Name*

First NameLast Name
Preferred Email Address*
example@example.com
Phone Number or Whats App Number*

Area CodePhone Number
Date of Birth*
Preferred Gender Pronoun Expression (if you wish to express these here): e.g. she/her, he/his, they/their, zie/hir.
How did you hear about this course?*
What interests you in participating in this course at this time? *
Do you have a regular practice of meditation? If so, what type and how many years have you been practicing? It’s not necessary to have any experience of meditation prior to this program.
Do you have any physical illness or limitation that may impact your participation in the program?*

YesNo
If yes, please describe.*
Are there any stressful life circumstances that might make this program difficult for you at this time (e.g., recent loss of a loved one or job, substance use, fasting). *
Is there anything else that might be helpful for the instructor to know at this time?
I understand that my participation in this program is entirely voluntary and I am free to withdraw at any time without penalty or prejudice. At the present time, I am planning to participate in the entire course, and to practice mindful self-compassion for about 20 min/day (formally or informally).*

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Today's date*

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Date

Waiver of Liability

I understand that courses offered through Still River Counseling, PLLC (AKA "Still River Counseling") are not individual or group therapy. These courses are designed to teach participants the tools needed to develop and cultivate a mindfulness, resilience and self-compassion practice. I acknowledge, represent and warrant that no provider-patient relationship is or will be formed with any facilitators/teachers as a result of my participation in one of the Still River Counseling courses, and/or that my participation in course work is separate and distinct from my normal provider-patient relationship with Still River Counseling facilitators/teachers.

I understand that Still River Counseling’s courses do not take the place or act as a substitute for personal therapy. I acknowledge that all decisions regarding my therapy will be made by me in consultation with an appropriate healthcare provider, and that Still River Counseling course facilitators have no ongoing role in treatment, therapy or associated recommendations for me.

I voluntarily agree to participate in activities during the online Still River Counseling Course and agree to abide by all processes and procedures of the program, as well as all instructions or directions during the course. I understand that participation in the course is at the discretion of the facilitators/teachers, at all times. If, in the opinion of the facilitators/teachers, I am unable to continue to participate productively in the course, I may be asked to leave.

I hereby assume all risks of personal injury to me and my property that may be sustained in connection with activities undertaken during the Still River Counseling course. Any costs incurred for services are my responsibility and not the responsibility of the teachers or the course facility. I agree to have reliable, consistent internet connectivity to participate virtually.

I understand that respecting the privacy of other class members is an important aspect of the course. I agree not to record the class sessions or discuss with outside people what was shared by other class members.

If I am taking prescription medications of any kind and discontinue taking them during the program, this may be grounds to terminate my ongoing participation in the course. I agree to abide by all recommendations and orders of my healthcare provider(s) outside of the course, if applicable, during the pendency of the course.

By completing this release and consent I solely assume all risk for any physical, mental and/or emotional consequences of participating in this online course.

I globally release and disclaim Still River Counseling and its teachers from all liability, of any form or sort, from my participation in the course. I also specifically and expressly agree to hold harmless, indemnify and release all facilitators and teachers of this program from any and all liability for the results of the educational guidance that will be or have been provided.

I understand that no guarantee is made as to the outcomes or results of this.
I sign this of my own free will. I am of legal age and accept the above disclaimer and authorization. By signing or typing my name below, I am agreeing and fully understand the contents of this waiver:*

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Today's Date*

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Emergency Contact Information
Emergency Contact Person - In case of emergency, the following person should be contacted:*

First NameLast Name
Relationship*
Daytime Phone*

Area CodePhone Number
Evening Phone, if different

Area CodePhone Number
Emergency Contact Email*
example@example.com

Payment Options
The cost of each course is 400 USD and 350 USD for discounted populations (K-12 teachers, currently enrolled students or resident physicians, first responders). Discount-eligible participants: please type "discount" in the coupon box. If you are eligible for the discount and registering for multiple courses, please email jennifer@stillrivercounseling and an invoice will be mailed to you.

We accept PayPal and Venmo for payments. If you are paying by Venmo, please send your payment to @stillriver (business card for the profile picture).

Please note that you are not registered for this course until you have submitted your payment.

Thank you! I look forward to practicing with you!

Jennifer

My Products

One course

$400.00

Two courses

$800.00

Three courses

$1,200.00

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Total

$0.00

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Still River Travels

Emergency Contact Information

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