Meditation Intake Form
Basic Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Age/DOB
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Questionaire
What benefits of meditation interest you? (check all that apply)
Physical Health
Mental Clarity
Emotional Balance
Spiritual Awakening
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)
mindfulness practice
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?
reclining meditation
seated meditation (chair or ground)
walking meditation
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)?
1
2
3
4
5
6
7
8
9
10
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?
Submit
Bear Foot Yoga, LLC
|
262-767-1111
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bearfootyogahealing.com
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