Online Mind-Body Skills Group with Tim, Tuesday 10a

Group dates and time

Group with Tim Wolfram, PsyD, LP
Group will be held Tuesdays, 10 AM - 12 PM on the following dates:

April 14
April 21
April 28
May 5
May 12
May 19
May 26
June 2

Please note that to get the most out of this experience, participation in ALL groups (barring unexpected events like illness or family emergency) is strongly encouraged. Also know that you are part of a group and your presence and participation impacts the others and the group process as a whole. As such, if you know in advance that you may have absences or you are unsure of your ability to commit to all 8 sessions, it is best to wait for another time.

Name

Occupation

Employer

Phone Number

Address

If you have a pronoun preference (she, they, he, etc.) please specify (optional)

I am 18 years old or older.*

Participants of Online Mind-Body Skills Groups must be 18 years of age or older.

Please tell us about yourself and why you are signing up for an Online Mind-Body Skills Group. Note that is information will be kept confidential and will only be shared with your group facilitator.

What is your level of experience with mind-body medicine?

Please mark any of our programs you have previously attended:

Food As Medicine
Mind, Mood & Food
Professional Training Program in Mind-Body Medicine
Advanced Training in Mind-Body Medicine

Would you like to be subscribed to CMBM's email list for newsletters and training announcements?

SMALL GROUP MODEL

By submitting this registration form, I am seeking to participate in eight Mind-Body Skills Groups. I understand that each group has a maximum of ten participants and one group facilitator. In each group I will be taught a mind-body technique (such as meditation, guided imagery, biofeedback, working with drawings, breathing, movement). The group combines didactic learning, experiential learning, practice and group support. An online Mind-Body Skills Group is an educational program and this experience is grounded in self-reflection modalities that may bring up strong, transformative emotions within oneself as well as being witness to other’s emotions and experiences within the online group. We find that sharing and connecting with others creates a wonderful learning environment, helping you become more self-aware and engaged in self-care.

Regular opportunities for sharing are offered in support of building both self-expression and connection with others. Sharing is encouraged yet unforced.

Yes, I am able to make a commitment of punctual attendance of all 8 online group sessions.*

Yes, I understand the groups require a willingness to engage in experiential exercise and active participation.*

Yes, I understand that groups may evoke emotions and the sharing of thoughts and emotions in myself and others.*

Yes, I understand it is my responsibility to keep all information shared in the small group confidential and to demonstrate respect for the other group members at all times. In the online setting, this also means 1) do not participate in the group in a public space or where others can see or hear the group activity; 2) do not share the group video conferencing login information with others. 3) Photos, screengrabs or recordings of the group sessions are prohibited. The only exception to this confidentiality rule is if any individual expresses an intent to harm themselves or others. Your group facilitator would be required to take additional action in support of the situation.*

Yes, I understand that I will be asked to participate in an anonymous evaluation upon the conclusion of the group series. It’s important for CMBM to evaluate the effectiveness of this program, and if necessary, to modify it to better meet group member’s needs.*

Yes, I understand that participation in this online group is not an equivalency for The Center for Mind-Body Medicine’s Professional Training Programs in Mind-Body Medicine*

Yes, I understand that after submitting this registration I will have a brief “meet and greet” using the video conference software (Zoom) with my small group facilitator to test out the technology, answer any questions, and make sure the program is right for me at this time. I understand that I am not considered fully registered and will not receive the Zoom meeting ID for accessing the online group until I have completed this “meet and greet” with my facilitator.*

Please indicate 2-3 times (date and time) over the next week that you are available for this "meet and greet." Your group facilitator will follow up to confirm.

We want to ensure that anyone who wants and needs to be in one of our Online Mind-Body Skills Groups is able to participate. Those of you who can afford a donation are essential to us continuing to bring our groups to all who need them. Our usual price is $375 for the eight sessions. If you are in the financial position to give this amount or more, we would be deeply grateful. If you need to donate less or are not able to make a donation at this time, you will not be turned away.

Donation

Total

$0.00

CANCELATION POLICY

Please understand that you are registering for a free Online Mind-Body Skills Group and that we expect the demand will, unfortunately, outweigh our ability to provide groups for everyone that wants to participate. We kindly request that you email our staff at [email protected] with as much advanced notice of your group start date if you are no longer able to participate so that we can offer your spot to another person.

Group size will range from 8-10 participants. In the event that fewer than 8 participants are registered for the group 7 days prior to scheduled start date, the group will be canceled and you will be notified.

Terms and Conditions Including Liability Release

PLEASE READ THIS SECTION CAREFULLY & COMPLETELY, AND SIGN THE BOX BELOW TO AGREE TO THESE TERMS AND CONDITIONS OF PARTICIPATION INCLUDING LIABILITY RELEASE.

I understand that Mind-Body Skills Groups are educational, supportive groups built upon developing self-care skills, but are not formal mental health therapy. I understand that the techniques recommended are not intended to be a substitute for conventional medical treatment, or to replace the medical decisions of my healthcare provider(s), whom I will consult prior to applying to participate if I am currently engaged in psychotherapy. All matters concerning my health are the responsibility of myself and my health care provider(s).

In an effort to facilitate a positive experience for its online group members, our Mind-Body Skills Groups are built upon Group Guidelines (previously described in this registration) intended to provide a safe place for all. CMBM reserves the right to remove from attendance and from enrollment at any current or upcoming online Mind-Body Skills Group or activity, anyone whose actions, in CMBM's discretion and judgment, are disruptive, violate the group guidelines, or otherwise interfere with the program. In such circumstances, CMBM retains the discretion to grant or withhold refunds of registration fees, in full or in part.

I understand and agree that participation in the group is for personal wellness and is a separate program from CMBM’s Professional Training Program in Mind-Body Medicine. As such, participation does not receive continuing education credits and cannot be counted towards attending CMBM’s Advanced Training in Mind-Body Medicine or Certification in Mind-Body Medicine.

LIABILITY RELEASE

In consideration of the services provided by The Center for Mind-Body Medicine (hereafter referred to as CMBM), I do hereby assume all responsibility for and all risk of, including but not limited to, damage or injury that may occur as a result of my own actions, inactions, or negligence, or that of others as a client of CMBM. I further understand that I am releasing and discharging any and all claims and causes of action of any kind or nature that are directed toward CMBM, including but not limited to, its officers, agents, and employees. This includes, but is not limited to, causes which are known or unknown, specifically mentioned or implied, or not mentioned nor implied, which might exist or be claimed to exist at or prior to the date of completion of this registration. The registrant further specifically waives any claim or right to assert that any cause of action or alleged cause of action or claim or demand has been, through oversight or error, intentionally or unintentionally omitted from this release. The terms herein shall serve as a release, indemnification, and assumption of risk for my heirs, executors, and administrators, and for all members of my family.

Signing the box below is the equivalent of an electronic signature and indicates acceptance of all of the above Terms and Conditions of Participation including Liability Release.

I, the undersigned, agree to the terms above.

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