Yoga Nidra Intake Form

Yoga Nidra Intake Form

Please fill out as much of this form as you are comfortable sharing. This is NOT a test! Try not to overthink any of the questions and simply respond with whatever comes to mind first. You are not required to fill out every question, but the more you share, the more refined your Yoga Nidra experience can be. There are no right or wrong answers! All information shared will remain 100% confidential between you and your Nidra guide, Dana Ripley of Embodied Mind Healing. All recordings are custom made to address your present moment needs and interests, with the overarching intention to bring the listener into a deep state of rest and relaxation. All in-person sessions may include sound healing, aromatherapy, movement, or energy work upon request.
Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
E-mail
example@example.com
Phone Number
Are you registering for the Zoom donation-based classes?

Yes, add me to the email notification list!No, I'm only interested in custom recordings.I want both!
How many versions of your custom recording would you like?

One long version (54 minutes, $108)One long, and one medium length (54 minutes & 27 minutes $144)2 versions, custom lengths ($177)None, I only want access to donation-based sessions.
If you would like 2 custom length versions, please list out the time lengths here:
For in person sessions, would you like to incorporate any of the following? (Additional $10 for one, 2 for 15, or all for $20)

Mindful movementEnergy work (reiki/polarity)Tuning Forks /singing bowlsAromatherapy
What draws you to the practice of Yoga Nidra? Do you have any specific intentions, goals, or aspects of self that you are wanting to heal?
Have you ever practiced Yoga Nidra? How often?
Do you practice Yoga or any other forms of mindful movement? If so, how often?
How often do you meditate? (if applicable)
Do you practice any forms of breathwork? What kind and how often?
What are you most curious to explore through your yoga and meditation practice?

How often do you experience the following?

	All the time	Sometimes	Very little	Not at all
Anxiety
Depression
Insomnia
Joy
Ease
Gratitude
Stress
Discomfort
Present
Forgetful
Tired
Focused
Connected
Relaxed
Creative
Fearful
Passionate
Disappointment
Pride
Laughter

Where in the body do you tend to carry stress?
Think of three people you admire and list one or two words to describe each person:
Do you experience chronic pain anywhere in the body? If so, where?
Are you sensitive to sound? If so, what sounds cause you distress?:
For recorded sessions, do you prefer a silent background or some gentle music to ease you in to the experience of stillness? All sessions will include at least some time in silence. List any specific sound/ music requests for your recording here.

Rate each of the following 0 to 5 - (0 = never true, 5 = always true)

I have enough time to live my dreams, goals and passions fully.

I believe my future is bright.

People hear and respect my truth.

I feel happiness, joy and peace.

I feel powerful beyond measure.

I feel optimistic and loved .

I experience DAILY ‘me’ time.

I love and embrace change.

Thinking about the past is joyful.

I speak and honor my truth.

I say ‘no’ when I need to.

I am happy and without anger.

I am fully supported by others.

I always have enough time.

I love challenge and struggle.

Please complete the sentence with the first thing that comes to mind:
I am blank .
Life is blank .
People are blank .
List three words to describe your relationship with your mother when you were growing up:
List three words to describe your relationship with your father when you were growing up:
How often do you remember your dreams?
List one thing you are ready to release:
List one thing you are inviting in to your life:
If you could wave a magic wand and change one thing about yourself or your life, what would it be? (if anything)
Are you spiritual or religious? Do you incorporate any spiritual practices into your daily life?
If you could develop any super-power, what would it be?
Is there anything else you would like to share?
Thank you for taking this time to reflect and share! If you have any aditional thoughts, feelings, ideas, and/or requests for your guided meditation, please reach out directly to Dana at ripleymassageandyoga@gmail.com.
Writing, recording, and editing your session may take up to 2 weeks, so please begin practicing with our free online sessions here: https://soundcloud.com/user-257008131
If any questions, insights, or other forms of feedback arise through your practices, please reach out!
We recomend tuning in at least once a week, and encourage you to try a daily Yoga Nidra practice as well. If time isn't on your side, simply listen as you fall asleep at night or set your alarm early in the morning to check in with yourself before the start of your day.

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Yoga Nidra Intake Form

Please complete the sentence with the first thing that comes to mind:

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