Meditation Intake Form
In order to ensure that we make the most of our meditation sessions together, I want to get to know you a little. This form is designed to help me understand your current life, what you hope to gain from meditating, and any specific needs you might have that may require me to make changes to my usual methods.

Please answer all questions as completely and honestly as you can. All answers are confidential and will only be used to create an ideal meditation session for you.

Email address *
What is your name? *
Your answer
Tell me a little about you and your life. (Ex: age, marital status, kids, career, etc.) *
Your answer
What do you hope to gain from meditation? (Ex: relieve stress, lower blood pressure, sleep better, have more patience, etc.) *
Your answer
What are the biggest areas of stress in your life right now?
Your answer
How does stress express itself for you (physically, emotionally and mentally)?
Your answer
Describe your previous experience with meditation, if any. *
Your answer
What is your biggest struggle with meditation (if any)?
Your answer
What kinds of self-care do you currently engage in?
Your answer
If you had 24 hours all to yourself, what would you do with the time?
Your answer
Describe your ideal vacation - where would you go, what would you do, who would be with you?
Your answer
Do you have any mental health concerns, such as depression, bipolar, anxiety, etc.? Please list them below. (This information will be kept confidential. It is solely so that I can ensure I do not create a meditation that may interfere with your mental health, such as a quick breathing meditation that may trigger your anxiety.) *
Your answer
Please list any physical health concerns you have, such as high blood pressure, asthma, arthritis, etc. (This information will be kept confidential. This is only so that I can make any necessary modifications to ensure your comfort during the meditation session.) *
Your answer
Do you have any questions or concerns that you would like me to address before our first session?
Your answer
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service