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Dear Applicant,

We have carefully assembled the following questions in order to help select the most suitable candidates for the Self-Compassion in Psychotherapy Program. Answers will necessarily include personal information viewed by the SCIP Team only and treated confidentially. Should you not want to answer any of the questions in writing, you may note this in the response area for that question and include contact information (telephone or email address) at which you can be contacted to discuss it privately. Similarly, the SCIP team may contact you to have a private conversation in order to clarify some of your answers on the form. Thank you.

Name*

First Last

Preferred name for use in correspondence (if different from above)

Please note your personal pronouns in the space below. Please leave blank if you prefer not to answer. (Why Pronouns Matter? Copy and paste this link into your browser to learn more https://www.mypronouns.org/what-and-why/)

Email*

Enter Email Confirm Email

Location / Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Preferred Language*

The SCIP Program is delivered in English language with some resources available in other languages.

If we are able to offer small groups in languages other than English, which languages would you choose?

check all that apply

Spanish
German
Chinese

Date of Birth*

Where did you first hear about the SCIP program?

Center for Mindful Self-Compassion (CMSC) newsletter or email
SCIP Facebook group
SCIP faculty member
SCIP graduate
Word of mouth
Awake Network
Cambridge Health Alliance Center for Mindfulness and Compassion

Referral Name

If you were referred by a specific person, please let us know so we can share our appreciation.

TRAINING PREREQUISITES

All SCIP participants must meet the following prerequisites before the course begins in October 2022:
1) Completion of a full MSC course prior to the beginning of the SCIP Program. This MSC course may be a standard 8-week program (in-person or online), a 5-Day Intensive MSC, or the CMSC’s Live Online (LOMSC) course. Short courses do not meet this pre-requisite.
2) Be a licensed or supervised mental health professional with active liability insurance.
3) Participants are expected to commit themselves to daily meditation practice for the duration of the course.

I understand that my application will be reviewed only if I meet the below prerequisite qualifications.*

*PLEASE NOTE: If you have any questions about whether you meet these requirements, please email the SCIP team before you fill out this application.

I meet these requirements.

EDUCATION & PROFESSIONAL QUALIFICATIONS

Title or Profession*

License Type*

License Number*

Education*

institution, degrees granted, years of graduation

Licensed as*

please check all that apply

Psychiatrist
Psychologist
Clinical Social Worker
Mental Health Counselor
Marriage and Family Therapist
Currently Enrolled Trainee in a Mental Health Field
Other (please describe)

Licensed as other

please describe

First year licensed*

Are you currently employed?

Yes
No
Private practice

Where are you currently employed?

What are your key duties in your practice?*

Please share a brief summary of relevant previous employment.

What are your areas of specialization and advanced training?

MINDFULNESS, MEDITATION & SELF-COMPASSION EXPERIENCE

List the details of the 8-week or 5-day intensive Mindful Self-Compassion program you have completed (year, location and teacher(s))*

Documented completion of a MSC course where you attended at least 6 of 8 sessions is required prior to the beginning of the SCIP certification program.

*Shorter programs like 2-Day workshops, core skills workshops, the “Power of Self-Compassion” program, and other adaptations do not meet this requirement.*

If you didn't finish (or start) your Mindful Self-Compassion course (LOMSC or MSC) yet, please list the type of program and the date you expect to finish. When you complete it, please send us your certificate.

Please attach a copy of your certificate, if available.

Allowed file extensions: jpg, gif, png, pdf, jpeg, doc, docx, pages

Max. file size: 50 MB.

What is your meditation experience?*

None
Some past practice
Current, regular practice

Please describe your personal mindfulness, compassion and self-compassion practices.*

When did you start meditating? How often do you practice? In what style or tradition do you practice?

Have you participated in any meditation retreats longer than a single day?*

Yes
No

Please provide details (date, location and teacher(s)) of any silent retretreats attended.

Do you have any experience teaching mindfulness or self-compassion to others?*

Yes
No

Please describe any experience you have with teaching mindfulness or compassion to others.

By checking the box below,*

I confirm that all answers are true, complete, and accurate

FEES

A $300 non-refundable fee is collected at the time of application. This deposit will be deducted from the total tuition described below.

The SCIP Program has a two tiered tuition model:
$5450 USD - Lend A Hand fee for those with the means to help others;
$4950 USD - Standard fee.
A Need A Hand fee for those with geographic or identity-based need may be requested.

Upon acceptance, tuition may be paid in full or in a two-part payment plan. All tuition must be paid in full by October 1, 2022.

Scholarship Request

Beyond the Need A Hand discounted fee, CMSC offers a limited number of partial scholarships that bring the total tuition to $2475 for accepted SCIP applicants whose need and experience may not allow them to afford participation otherwise. Please indicate below if you wish to receive a scholarship application upon acceptance into the program.

Yes

SCIP Cohort 3 - Application Fee 4306

Non-refundable application fee is required to submit your application.

Code

SCIP Cohort 3 Application Fee

Non-refundable application fee is required to submit your application.

$0.00

Credit Card*

Card Details

Cardholder Name

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