Stoked Life Mantra Meditation Client Form

Name

First NameLast Name

Phone Number

Area CodePhone Number

E-mail

Gender

MaleFemale

Age

Occupation

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

EMERGENCY INFORMATION

Emergency Contact's Name

First NameLast Name

Relationship

Emergency Contact's Phone Number

Area CodePhone Number

How did you hear about STOKED LIFE?

What is your main purpose or goal for your mantra meditation work with Jess? Is there a particular area of your life you are wanting support?

How would you describe your experience with meditation?

How would you describe your experience with mantra meditation specifically?

If you meditate regularly, please describe what this typically looks like & the approximate frequency & duration that you usually practice?

If you DO NOT practice meditation regularly, what would you consider to be your greatest challenge in regards to your ability to practice?

Do you have any injuries, limitations or other health concerns that may interfere with your practice that I should be aware of? e.g. a knee injury that may require a different seated position for your meditation practice

NoYes

If yes, please provide details below:

Please list any health concerns I should be aware of.

Are you pregnant?

NoYes

If yes, how far into your pregnancy will you be at our first session?

CANCELLATION POLICY

Please note a cancellation fee of $40 applies if there is less than 24 hours notice.

REFUND POLICY

For MANTRA SET UP ONLY: No refunds are offered.

For MANTRA SET UP WITH ONGOING SUPPORT: To receive the best value I ask you to commit to the full 3 sessions. However, if - after paying for the full package - you come to the first session and for some reason do not wish to continue, a refund for the difference between MANTRA SET UP ONLY and MANTRA SET UP WITH ONGOING SUPPORT will be offered.

CLIENT STATEMENT

By signing this form you are declaring that:

You have carefully read & understood the Cancellation & Refund Policies.
You understand and acknowledge that mantra meditation practices are known to support mental and physical wellbeing, and to relieve stress. However they do not replace medical care. STOKED LIFE does not diagnose, prescribe or medically treat any condition or disorder.
STOKED LIFE does not provide psychological counselling and/or talk therapy for specific mental health issues or traumas.
You understand to get the maximum gain from your sessions, it is recommended that you rearrange your priorities outside of your sessions to accomodate your mantra practice [solo practice sessions are typically either 15 or 30 mins most days, or at a minimum twice per week].

SIGNATURE

This statement is being signed voluntarily.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Name

First NameLast Name

Date

Thank you so much for taking the time to complete this form.