Dr. Kody's Workshop and Class Registration Form

www.drkody.com

Please correct the errors described below.

Workshop or Class Selection

Please select your class choice from the drop-down menu.

Background Information

Please provide the following background information. This information will only be read by Dr. Kody to support you in the workshop or class. If you feel uncomfortable answering any questions, please note that on the form and we can have a private conversation before the program begins. Leaving a question blank will have no impact on inclusion in the program. Thank you.

This email address will be used for all class updates.
Please use the best phone number to reach you.

Workshop & Class Consent & Participation Agreement:

Section 1: Program Participation Agreement & Waiver

Please type your first and last name as your legal signature to indicate that you, understand, accept, and agree with the information above.

Section 2: Registration Fee and Cancellation Policy Agreement:

Please type your first and last name as your legal signature to indicate that you understand, accept, and agree with the information above.

Section 3: MSC Participants Only

Section 3A: MSC Online 8-week Class Fee

Payment Method

For those NOT using insurance benefits and paying pay credit card:

Section 3B - Billing Information for MSC Participants Choosing to Use Insurance Benefits (optional):

Please type your first and last name as your legal signature to indicate that you understand, accept, and agree with the information above.

Section 3C: MSC Summer Class Schedule

Please type your first and last name as your legal signature to indicate that you understand, accept, and agree with the information above.

Section 3D: MSC Class Content & Self-Care Agreement

Please type your first and last name as your legal signature to indicate that you understand, accept, and agree with the information above.

Welcome!

I'm delighted that you are joining the MSC adventure ahead! I look forward to getting to know you and to circling up this summer to practice Mindful Self-Compassion together. Once your registration is complete with this form and payment, your spot will be reserved. You'll gain access to the online classroom by July 5th. I'll be using a private online classroom for pre/post live class resources. I'll email Zoom links by the morning of each class. Please feel free to contact me by email or phone if you have any questions. *Don't forget to sign up for a free 1:1 Introduction to MSC Online Session. https://www.signupgenius.com/go/904044da4ae2da5fc1-11introduction *Don't forget to purchase the workbook. It's called The Mindful Self-Compassion Workbook: A Proven Way to Accept Yourself, Build Inner Strength, and Thrive by Kristin Neff and Chris Germer. *If you're using insurance benefits, please ensure that your insurance plan will cover online group services (90853). If you're not a current client at Carli's private practice and would like to use insurance benefits, please send me an email to obtain the required paperwork. Kind regards, Dr. Carli Kody dr.carlikody@gmail.com

Your information will be encrypted.