This Disclosure, Consent and Waiver Form (“Form”) is entered into by the undersigned person (“Participant”) who wishes to participate in telephonic group-training and meditation practice sessions conducted by Shelly Young, MA, LPCC, LADAC. These group sessions will provide coaching and information on the techniques of mindfulness meditation following the Basic Mindfulness system pioneered by Shinzen Young. The emphasis will be on techniques relevant to issues of suffering related to one or more of the following: anxiety, panic, obsessive/compulsive issues.
The group sessions will follow an open-forum format and be strictly confidential. Participants will be encouraged to join in the program, freely sharing their personal experiences and asking questions concerning the program material. Participants may also choose to remain silent. As moderator, Shelly will screen the participants prior to the program through the registration process. Shelly reserves the right to exclude any applicant from the group or cut off any participant who she deems to be disruptive or inappropriate in order to achieve maximum effectiveness for all participants.
Only first names will be used during the sessions. Shelly urges all participants to act thoughtfully and respectfully towards others, and to protect the confidences of others. Shelly is required to maintain confidentiality with all participants.
Shelly is a Licensed Professional Clinical Counselor in New Mexico, and the laws and regulations of that State will apply. Although she is a trained and licensed therapist, she will be acting as a teacher and coach during the sessions.
Mindfulness has the potential for bringing out painful emotions. Participants need to have their own support system in place and be prepared to cope with increased emotional vulnerability if it should occur.
Participant has fully read and understood this Form, and consents to its terms, and any implied risks, with full knowledge of its meaning and contents. Participant is aware that others may be disruptive and that anyone may be stopped from participating or dismissed at any time (in which case they will be entitled only to a refund); that Shelly, as moderator, must use her discretion to manage the sessions in order to protect the group. Participant waives the right to attempt in any way to enforce the laws of any jurisdiction other than New Mexico with regard to their participation in the program. Participant confirms that he or she is the person who has applied to participate in the sessions, and that the information given on the registration form is true and correct to the best of their knowledge.