Guided Meditation Client Intake Form
I. Personal Information
First Name
Last Name
Date of Birth
Phone Number
Email Address
Street Address
City/Suburb
State/Province
Postal/Zip Code
Emergency Contact Name
Phone Number
II. Meditation Experience & Goals
Have you meditated before?
If yes, what types of meditation have you practiced? (e.g., mindfulness, loving-kindness, transcendental, etc.)
How often do you currently meditate?
Daily
Several times a week
Weekly
Occasionally
Never
What are your primary goals for engaging in guided meditation? (Check all that apply)
Stress reduction
Relaxation
Improved sleep
Increased focus and concentration
Emotional regulation
Spiritual growth
Pain management
Increased self awareness
Other:
What specific areas of your life would you like to address through meditation?
III. Health & Well-being
Do you have any physical health conditions or limitations that might affect your ability to participate in meditation?
If yes, please specify.
Do you have any mental health conditions or have you been diagnosed with any mental health disorders?
If yes, please specify.
Are you currently under the care of a physician or therapist?
If yes, please specify.
Are you currently taking any medications?
If yes, please specify.
Do you experience any of the following? (Check all that apply)
Anxiety
Depression
Panic attacks
Insomnia
Chronic pain
PTSD
Other:
Are there any specific triggers or sensitivities that I should be aware of? (e.g., certain sounds, scents, physical positions)
IV. Service Selection
Please indicate which services you are interested in and any specific preferences.
Please indicate your preferred type of meditation session:
Individual Session
Group Session
Please indicate your preferred meditation format:
In-Person
Online (Zoom, etc.)
Please select the type(s) of guided meditation you are interested in: (Check all that apply)
Mindfulness Meditation
Loving-Kindness Meditation
Body Scan Meditation
Visualization Meditation
Sleep Meditation
Chakra Meditation
Breathwork based Meditation
Custom Meditation
Please specify your needs:
Group Sessions:
What days of the week are you available?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What time of day are you available?
Morning
Afternoon
Evening
Individual Sessions:
What days of the week are you available?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What time of day are you available?
Morning
Afternoon
Evening
Are you interested in a specific length of session?
30 minutes
45 minutes
60 minutes
Other (please specify):
V. Suitability & Informed Consent
Are you willing to commit to regular practice to maximize the benefits of meditation?
Do you understand that guided meditation is not a substitute for professional medical or psychological treatment?
Are you comfortable with the possibility of experiencing emotional or physical sensations during meditation?
Do you have any questions or concerns before beginning guided meditation sessions?
I understand that all information provided in this form will be kept confidential, except where legally required
I acknowledge that I have read and understood the information provided in this intake form and consent to participate in guided meditation sessions.
Client Signature
Client Intake Form Insights
Client Intake Form Insights
Please remove this client intake form insights section before publishing.
Let's break down the Guided Meditation Client Intake Form and delve into the insights it provides, both for the practitioner and the client.
Insights for the Practitioner:
Client History and Experience:
- The form reveals the client's prior experience with meditation, which is crucial for tailoring sessions. A beginner will require a different approach than someone with years of practice.
- Understanding the types of meditation they've tried helps gauge their familiarity with various techniques and potential preferences.
Client Goals and Motivations:
- The "Goals" section is vital for understanding what the client hopes to achieve. This allows the practitioner to align the meditation sessions with the client's specific needs (e.g., stress reduction, sleep improvement, spiritual growth).
- Knowing the "specific areas of life" they want to address allows the practitioner to focus the meditation themes appropriately.
Health and Safety Considerations:
- The health section is paramount for ensuring the client's safety. It helps identify any physical or mental health conditions that might contraindicate certain meditation practices or require modifications.
- Knowing about medications, triggers, and sensitivities allows the practitioner to create a safe and comfortable environment.
- It is critical to know if they are under the care of a physician or therapist. If they are, it might be necessary to get permission from that professional before beginning meditation sessions.
Service Preferences:
- The "Service Selection" section helps the practitioner understand the client's preferences regarding session format (individual/group, in-person/online), meditation types, and session length.
- This information allows for personalized service delivery and ensures client satisfaction.
Suitability Assessment:
- The "Suitability & Informed Consent" section helps the practitioner determine if the client is a good fit for guided meditation and if they understand the nature of the practice.
- It also protects the practitioner by ensuring that the client acknowledges the limitations of guided meditation and understands that it's not a substitute for professional medical or psychological treatment.
- The practitioners notes section, allows for tracking of the clients progress, and any observations that the practitioner may have.
Insights for the Client:
Self-Reflection and Awareness:
- The form encourages clients to reflect on their meditation goals, health conditions, and personal preferences. This process can increase self-awareness and clarify their intentions.
- It prompts them to consider their readiness to commit to regular practice and explore their motivations for seeking guided meditation.
Clear Communication and Expectations:
- By providing detailed information, clients can ensure that the practitioner understands their needs and can tailor the sessions accordingly.
- The consent section helps clients understand the nature of guided meditation and the practitioner's role.
Personalized Experience:
- The form empowers clients to express their preferences and customize their meditation experience.
- This can lead to a more effective and enjoyable meditation practice.
Safety and Well-being:
- The health section encourages clients to be honest about their health status, which is crucial for ensuring their safety during meditation sessions.
Overall Importance:
The client intake form serves as a valuable tool for building a strong client-practitioner relationship, ensuring safety, and providing personalized guided meditation services. It promotes open communication, mutual understanding, and a foundation for a positive and transformative meditation experience.
To configure an element, select it on the form.