Meditation Form

Meditation Form

Tell us more about your meditation goals
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
1. How many times do you currenltly meditate per week?

1 - 2 Times2 - 3 Times3 - 5 Times5 - 7 TimesOther
2. How many times would you like to meditate per week?

7 (Daily)6 - 5 Times3 - 4 Times1 - 2 TimesOther
3. How long are you able to meditate for?

5 Minutes10 Minutes20 Minutes30 Minutes1 hourOther
4. How long would you like to meditate for?

5 Minutes10 Minutes20 Minutes30 Minutes1 hourOther
5. Do you experience any of the following physical symptoms when meditating? (Click all that apply)

Pins & needles in feet or legsBack AcheSore NeckNumbess in feet or fingers & handsTense shouldersTense or clenched jawOther
6. What would you like to experience while meditating? (Click all that apply)

RelaxationCalmnessEnergisedOneness/ConnectionLoveJoyOther
7. What ongoing benefits would you like to see in your life as a result of your meditation practice? (Click all that apply)

Reduced stressImproved sleepBetter relationshipsImproved focus & concentrationSelf compassionEmpathyCreativityOther
8. You have tried meditation before, and have found it hard at times to centre your attention.

TRUEFALSE
9. What symptoms have you noticed when you struggle to stay centred? (Click all that apply)

RestlessnessBoredomDiscomfort (emotional)ThoughtsOutside distractions/interruptions
10. Have you been clinically diagnosed with a mental health condition or learning challenge, please provide information; (include in your answer whether you are currently receiving medical/psychiatric/psychological support).
11. I would like help with... (Click all that apply)

Receiving guidance from an accredited & experienced meditation teacherBecoming comfortable with my own mind and bodyImproving my relationship with my thoughtsSupporting my spiritual health & wellbeingSupporting my mental/emotional health & wellbeingSlowing downExperience more positive emotions (joy/love/contentment/happiness/freedom)Managing anxietyOther
12. What time of day do you prefer to meditate?

Before SunriseMorningAfternoonEveningBedtimeOther
13. Would you prefer to meditate...

After eating?Before eating?Whilst eating?With cup of tea?With cup of coffee?Not sure?Other
14. Would you prefer to meditate...

OutsideInsideBothEither
15. Have you attended an in-person meditation group before?

YESNO
16. Have you attended an online meditation group before?

YESNO
17. Do you have a preference for meditating in a group?

In-personOnlineEitherOther
18. Have you worked with a meditation coach or mentor before?

YESNONot sureOther
19. Would you prefer to meditate & receive support one on one or in a small group?

One on oneSmall groupNot sureOther
20. What days and times best suit you to attend a meditation group or 1:1 online session? (Click all that apply)

Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PMSaturday AMSaturday PMSunday AMSunday PMOther
21. What would you find most helpful at this stage in your meditation practice? (Click all that apply)

A meditation in-person course designed to cover the basics and support beginnersAn online course that is self-paced with optional one on one supportA meditation workshop focused on a theme/technique (ie. mindfulness, movement, sound healing, nature)A casual meditation group (in-person)A casual meditation group (online)One on one coaching/mentoringGuided meditation audios to listen in your own practice timeA meditation retreatOther
Payments:

You can pay with cash, card or direct transfer on the day of your session. (Please note that there is a 1.9% surcharge on all card payments).

A note on confidentiatlity:

Your information will be respected and kept confidential. This form is designed to assist us in helping to support our clients by obtaining some more specific information about their situation and experience so that we may design sessions and programs which best meet the needs of our valued clients.

Questions/Comments?

Email: Jacqui at shinemeditation@outlook.com

Book in an initial obligation free 15 min zoom information session to see if personalised meditation coaching feels like the right fit for you. Email Jacqui to organise a time.
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