Pre-session Intake Form

Pre-session Intake Form

Share a few details to help tailor your initial session. This isn't a substitute for medical or mental health treatment; it is background information to help prepare for the call.
Please take a moment to answer each question thoughtfully. Your responses will help us better support your sessions and goals.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What brings you to mindfulness and meditation?
Have you practiced mindfulness or meditation services before?
If yes, please describe your previous experience.
What are your main goals for practicing mindfulness and meditation?
Are there any current challenges or stressors you'd like to share?
Do you have any health conditions or concerns we should be aware of?
How would you rate your mental health? (1=poor, 10=great) explain your answer
How would you rate your physical health? (1=poor, 10=great) explain your answer
How would you rate your spiritual health? (1=poor, 10=great) explain your answer
What is your preferred approach to mindfulness/meditation? (Optional) 1- Purely secular / evidence-based / non-spiritual, 2- Spiritual but not affiliated with a specific religion, 3- Aligned with a specific religious or spiritual tradition (Feel free to specify: ______), 4- Other: Prefer not to say
How would you prefer your sessions to be conducted?

Other
What days and times are generally best for you?
Should be Empty: