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Intake Questionnaire
Understanding the impact of meditation in your everyday life can help the Unmasking Mindfulness team keep track of your progress and adjust your lessons. For this reason, this questionnaire was specifically developed for people participating in Unmasking Mindfulness. Thank you for your willingness to complete this form.

INSTRUCTIONS:
Please answer each question in its entirety. Allow yourself sufficient time to answer all of the following questions. This questionnaire should take approximately 10 minutes.
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Email *
First Name *
Last Name *
Date of Birth *
MM
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DD
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YYYY
Gender *
During the past two weeks, have you been out of school or work for reasons NOT related to your health? *
What is your current marital status? *
Which of the following best describes your racial background? *
What is the highest level of education you have completed? *
Which of the following best describes your current work or school status? *
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