MediSoul Institute Intake Form

MediSoul Institute Intake Form

Thank you for choosing to book a personalized meditation session. Please fill out this form to help us tailor your session to your unique needs and goals.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemale
Time Zone:*
Phone Number*
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Age*
Preferred Contact Method:*

EmailTextPhone
Marital Status*

SingleMarriedDivorcedWidowed
What is your meditation experience Level:*

Never meditated beforeBasic knowledge of meditationMeditate occasionallyMeditate often
If you have meditated, what type(s) of meditation have you practiced?*

Mindfulness MeditationLoving-Kindness MeditationGuided VisualizationBody Scan MeditationTranscendental MeditationZen MeditationVipassana MeditationChakra MeditationMantra MeditationSound MeditationQigong MeditationWalking MeditationBreath Awareness MeditationKundalini MeditationEnergy Healing MeditationNever meditatedI am not sure
What are your primary goals for this session?*
Please describe your current challenges or reasons for seeking meditation:*
Are there any physical, mental, or emotional conditions we should be aware of?*
What changes would you like to make in your life right now?*
What is your motivation in life?*
What are your expectations from this meditation lesson relationship?*
I understand that our session will be conducted through Zoom:*

I UnderstandI don't understand
Agreement/Reminders:

- I understand that all information I entered in this form will be considered strictly confidential.

- The data gathered from this form will only be used as a basis for tailoring my meditation session.

- I acknowledge that the services provided are for personal growth, relaxation, and spiritual development. These services are not a substitute for medical or psychological care.

- I understand that Holly Janes is not a doctor, licensed therapist, or health care professional, and meditation sessions are not intended to diagnose, treat, or cure any medical or psychological condition.

- I agree that it is vital to follow the plan and guidance agreed upon by both myself and the meditation coach to achieve the best outcomes.
How did you find out about our services?

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Write where you found us:*
If someone referred you, what is their name:
Would you like to receive our newsletter with updates on courses, classes, and discounts?*

YesNo
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