Marcelletta Miles, LLC
MASC™ INTEREST FORM
How did you find out about the self care retreat?
*Name of person who referred you
INTENTIONS AND GOALS
What types of services are you most interested in?
What self-care challenges are you facing? (Check all that apply)
Are you at the top in your organization and feeling overwhelmed with all the responsibility and little time to get things accomplished?
Are you suffering from compassion fatigue due to your work in healthcare?
Do you find your current self-care techniques are not rewarding, replenishing and fulfilling
Do you want to make more time available for priorities outside of work: young children, teenage kids, a dying or very sick family member, obtaining a
Do you find yourself stressed due to your career, family or finances?
Does your intentions come from a place of judgment instead of love and compassion?
Are you always saying “yes” to others when you really mean “no?”
You do want to learn more about mindfulness-based stress reductions techniques?
Do Not Fill This Out