Student Intake Form — Mindful with Hazel

Student Intake Form:
One one One Meditation Session

Ready to move forward?
Tell me about you so we can gets started.

Name

First Name

Last Name

Phone

(###)

###

####

Gender

Male

Female

Other/Prefer not to disclose

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What's your meditation experience, if any?

How long have you been practicing meditation? What types of meditation have you practiced before?

Reasons for seeking one on one meditation?

What are your primary reasons for seeking one-on-one meditation sessions? What specific challenges or issues do you hope to address through meditation?

Goals and Expectations

What do you hope to achieve or gain from these sessions? Are there any specific goals or intentions you have in mind for your meditation practice?

Health and Wellbeing

Health and Well-being: Do you have any physical limitations or health concerns that may affect your ability to participate in meditation sessions? (Yes/No, if yes, provide details) Are you currently receiving treatment for any mental health conditions? (Yes/No, if yes, provide details)

Availability Preferences

What days and times are you typically available for sessions?

Additional Comments

Is there anything else you'd like to share or want Hazel to know?

Acknowledgement + Consent

By submitting this form, you acknowledge that the information provided will only be used for the purpose of arranging and conducting meditation sessions. You acknowledge that Hazel is a mindfulness meditation teacher, not a licensed therapist. These one-on-one sessions are designed to offer guidance and instruction in mindfulness practices, and are not a replacement for professional therapy or medical treatment. If you have any concerns about your mental or physical health, it's advisable to consult with a qualified healthcare provider.

Student Intake Form:One one One Meditation Session

Student Intake Form:
One one One Meditation Session