Pre-Course Questionnaire

Thank you for registering for an Eat Breathe Thrive course! This questionnaire is designed to help your course facilitator(s) cater the course to your unique personal needs and goals. Please complete and submit the questionnaire prior to your first session.

About You

Name:*

First NameLast Name

Location:*

Street Address

Street Address Line 2

CityState / Province

Country

Phone Number:*

Email:*

example@example.com

Age:*

Ethnicity:*

Non-Hispanic White or Euro-AmericanBlack, Afro-Caribbean, African American, or African EuropeanLatino, Hispanic American, or Hispanic EuropeanEast Asian, Asian American, or Asian EuropeanSouth Asian, Indian American, or Indian EuropeanMiddle Eastern, Arab American, or Arab EuropeanNative American or Alaskan NativeOther

Please specify your gender identity:*

Please specify your sexual orientation:*

What is your household income? (Please answer in the most appropriate currency)*

What is your household income?

Course Details

Which course are you enrolled in?*

Which Online Immersion are you registered for?

What is the name of your course facilitator?*

How did you hear about the course?*

Who referred you to this course?

Which organization or professional referred you to this course?

Through which social media channel did you hear about the series?

Your Health Matters

The following conditions might require specific modifications for your yoga practice. Please tick any conditions that you experience from the list below:

Please give further explanation if necessary:

Are you/could you be pregnant, or have you given birth in the last six weeks?

YesNo

Do you have any old injuries that still trouble you?

YesNo

Please describe:

This course deals with the topic of mental health. Do you experience any of the following? (Please tick all which apply)

Please specify below any other mental health challenges you would like us to know about:

Have you ever been diagnosed with an eating disorder?

YesNo

Please check all which apply:

Dates of illness:

Have you received treatment for an eating disorder before?

YesNo

Please select the type(s) of treatment you have received from the list below:

Your Professional Background

Do you teach yoga?*

YesNo

Which type(s) of yoga? (Please tick all which apply)

How long have you been teaching yoga?

Are you a mental health professional?*

YesNo

What type of mental health professional are you?

Are you a health professional?*

YesNo

What type of health professional are you?

Are you an educator?*

YesNo

Which age group(s) do you teach?

Are you interested in becoming an Eat Breathe Thrive facilitator in the future?

YesNoMaybeI don't know what this is

Previous Experience of Yoga and Meditation

Have you practiced yoga before?

YesNo

Which type(s) of yoga? (Please tick all which apply)

How long have you been practicing yoga?

How often do you practice yoga?

Have you practiced meditation before?

YesNo

What kind(s) of meditation have you practiced?

Do you have a regular meditation practice?

YesNo

How often do you practice meditation?

Pre-Course Questionnaire

About You

Course Details

Your Health Matters

Your Professional Background

Previous Experience of Yoga and Meditation

Emergency Contacts

Emergency Contact 1

Emergency Contact 2

Your Goals