Meditation Intake Form
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What benefits of meditation interest you? (check all that apply)
What is your goal or purpose?
Do you have experience with any of the 3 basic types of meditation (check all that apply):
cognitive meditation (mindfulness meditation, internal dialogue/external stimulus)
focused or attention based training (mantra, breathing, imagery, guided meditation)
compassion and gratitude based training (loving kindness, heart centered)4
If you have prior experience with any of the above mentioned aspects of meditation, what did you like / dislike?
What meditation tools might interest you? (check all that apply)
Mantra Meditation (Transcendental Meditation), Chanting
Pranayama Breathing Techniques
Guided Relaxation and Imagery
Mudras (energetic hand gestures)
Subtle Body Attunement (chakras/tantra)
Compassion or Gratitude focus
Develop current personal Religious or Spiritual traditions
What position would be best for your body and goals?
seated meditation (chair or ground)
Please list any challenges (physical and emotional), illnesses or injuries you want to address or that may affect your meditation practice.
Who else are you currently seeing for health concerns or lifestyle wellness? How often do you see them?
How would you rate your current level of stress on a scale of 1-10 (1 low, 10 high)?
What are your spiritual beliefs / practices / affiliations (Is your belief a source of support to you?)
How much time can you put aside daily or weekly for meditation? What time of the day would you be most disciplined to do your meditation practice?
Bear Foot Yoga, LLC
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