Mindful Self-Inquiry Support Group Intake
Standard online intake form using the questions and consents extracted from the PDF. Please answer all required fields and review the consent statements carefully.
Client Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Motivation and Background
What drew you to this group?
*
What are you hoping to gain from participating?
*
Have you participated in any of the following before?
Meditation group
Support group
Therapy group
Breathwork workshop
Retreat
Other
If you have experience with meditation, mindfulness, journaling, yoga, or other reflective practices, tell us a little about it:
Are there particular topics, patterns, or areas of growth you're interested in exploring?
Current Support and Facilitator Notes
Are you currently working with a therapist, counselor, coach, or other support professional?
*
Yes
No
If yes, feel free to share more
Is there anything you'd like the facilitators to know that would help support your participation in the group?
*
Consent and Acknowledgements
Initials: I understand this is a support and personal growth group, not psychotherapy.
*
Initials: I understand that group members are asked to respect the confidentiality of others.
*
Initials: I understand that participation is voluntary and that I may choose my level of sharing.
*
Initials: I understand that mindfulness, breathwork, journaling, and self-reflection practices can bring up emotions, and I will participate at a pace that feels appropriate for me.
*
Initials: I understand that consistent attendance helps create a supportive group experience for everyone.
*
Submit
Should be Empty: