Contact Info

Email Address

Mailing Address

Family responsibilities and role, both immediate and extended

Children

How many children do you have? What are their ages? Describe their general health

Do you have a support system that you connect with regularly?

Describe your sleep quality.

How many caffeinated drinks do you have a day and what type are you drinking?

Describe the type of food you generally eat.

Describe your exercise habits.

Describe your use of drugs and/or alcohol and frequency of use.

If yes, please describe.

Describe current medical and health issues and status.

How do these health issues affect your life?

Do you experience any chronic pain? If yes, please describe.

What is your experience with meditation and mindfulness?

What do you do for fun? What are your hobbies? How do you fill your free time?

What is most important to you?

What worries you?

What gives you pleasure in your life?

What are your meditation goals?

Pre-program

Survey