Course Registration Form

Yoga Nidra Student Registration Form

Please fill out this form to your best ability. This is NOT a test! Do not to overthink any of the questions and simply respond with whatever comes to mind first. You are not required to fill out every question, but the more you share, the more refined your Yoga Nidra experience can be. There are no right or wrong answers! All information shared will remain 100% confidential between you and your Nidra guide.
Student Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
E-mail
example@example.com
Phone Number
Yoga Nidra is one of the safest forms of therapy because it utilizes the natural process of sleep to support balance and vitality on all layers of our being. No physical effort is required, making the practice accessible to all! Are there any specific injuries, medical conditions, psychological challenges, or ailments of the heart you would now like to heal through Yoga Nidra?
Have you ever practiced Yoga Nidra?
Do you practice Yoga or any other forms of mindful movement? If so, how often?
How often do you meditate? (if applicable)
Do you practice any forms of breathwork? What kind and how often?
What are you most curious to explore through your yoga and meditation practice?

How often do you experience the following?

	All the time	Sometimes	Very little	Not at all
Anxiety
Depression
Insomnia
Joy
Ease
Gratitude
Stress
Discomfort
Present
Forgetful
Tired
Focused
Connected
Relaxed
Creative
Fearful
Passionate
Disappointment
Pride
Laughter

Where in the body do you tend to carry stress?
Think of three people you admire and list one or two words to describe each person:
Are you sensitive to sound? If so, what sounds cause you distress?:
Yoga Nidra is traditionally practiced in silence, however, we have found sound to be a powerful tool for balancing the nervous system and moving energy. In the state of Yoga Nidra, we become very open and receptive to soundwaves, making these two modalities a powerful combination for healing. On a scale from 1-5, how much sound would you like to incorporate into your sessions? (1-no sound, 5-I want sound for the full session!)
Do you prefer nature sounds, music, or a mix of both? List any specific sound requests here.

Rate each of the following 0 to 5 - (0 = never true, 5 = always true)

I have enough time to live my dreams, goals and passions fully.

I believe my future is bright.

People hear and respect my truth.

I feel happiness, joy and peace.

I feel powerful beyond measure.

I feel optimistic and loved .

I experience DAILY ‘me’ time.

I love and embrace change.

Thinking about the past is joyful.

I speak and honor my truth.

I say ‘no’ when I need to.

I am happy and without anger.

I am fully supported by others.

I always have enough time.

I love challenge and struggle.

Please complete the sentence with the first thing that comes to mind:
I am blank .
Life is blank .
People are blank .
List three words to describe your relationship with your mother when you were growing up:
List three words to describe your relationship with your father when you were growing up:
How often do you remember your dreams?
Describe your relationship to religion and/or God. Has this relationship changed through the course of your life?
List one thing you are ready to release:
List one thing you are inviting in to your life:
If you could wave a magic wand and change one thing about yourself or your life, what would it be? (if anything)
If you could develop any super-power, what would it be?
Is there anything else you would like to share?
Thank you for taking this time to reflect and share! If you have any aditional thoughts, feelings, ideas, and/or requests for your guided meditation, please reach out directly to Dana at ripleymassageandyoga@gmail.com.
Writing, recording, and editing your session may take up to 2 weeks, so please begin practicing with our free online sessions here: https://soundcloud.com/user-257008131
If any questions, insights, or other forms of feedback arise through your practices, please reach out!
We recomend tuning in at least once a week, and encourage you to try a daily Yoga Nidra practice as well. If time isn't on your side, simply listen as you fall asleep at night or set your alarm early in the morning to check in with yourself before the start of your day.
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Yoga Nidra Student Registration Form

Please complete the sentence with the first thing that comes to mind: