Corporate Mindfulness Programs Participant Intake Form

Thank you for considering our services to enhance the well-being and productivity of your organization. This intake form is designed to help us understand your needs and tailor our mindfulness programs to best suit your company. Please take the time to fill out this form thoroughly.

Company Information

Company Name

Company Industry

Number of Employees

Primary Contact Person

First Name

Last Name


Job Title

Email Address

Phone Number

Location(s) of Employees

Program Objectives

What are your primary goals for implementing a mindfulness program? (Check all that apply)

What challenges is your company currently facing that you hope a mindfulness program will address?

Have you previously implemented any wellness or mindfulness programs?

Program Preferences

What type of mindfulness services are you interested in? (Check all that apply)

Preferred Duration of Program:

Preferred Time for Sessions:

Do you have any specific mindfulness techniques or practices you would like to include? (e.g., meditation, breathing exercises, body scans, mindful walking)

Employee Engagement

How do you plan to encourage employee participation?

What percentage of employees do you expect to participate?

Do you have any specific employee groups or departments you would like to target? (e.g., leadership, sales, customer service)

Logistics and Budget

What is your estimated budget for the mindfulness program?

Do you have any specific logistical requirements? (e.g., space for on-site sessions, technology for virtual sessions)

Are there any specific dates or timelines you would like the program to align with? (e.g., quarterly goals, company events)

Additional Information

Is there anything else you would like us to know about your company or employees that could help us tailor the program?

How did you hear about us?

Next Steps

Would you like to schedule a consultation to discuss your needs further?

Preferred Method of Contact:


Thank you for completing the Corporate Mindfulness Programs Intake Form!


Client Intake Form Insights

Please remove this client intake form insights section before publishing.


The Corporate Mindfulness Programs Participant Intake Form is a comprehensive tool designed to gather essential information from businesses interested in implementing mindfulness programs. The form is structured to ensure that the mindfulness service provider can tailor their offerings to meet the specific needs, goals, and constraints of the client organization. Below is a detailed breakdown of each section and its purpose:

Section 1: Company Information

Purpose: To gather basic information about the company and its structure.

  1. Company Name: Identifies the organization.
  2. Industry: Helps understand the industry context, which may influence the type of mindfulness program needed (e.g., high-stress industries like finance vs. creative industries like advertising).
  3. Number of Employees: Determines the scale of the program and whether it should be tailored for small, medium, or large organizations.
  4. Primary Contact Person: Ensures clear communication channels with the right person in the organization.
  5. Location(s) of Employees: Important for logistical planning, especially if the company has multiple offices or remote workers.

Section 2: Program Objectives

Purpose: To understand the company’s goals and challenges, which will guide the design of the mindfulness program.

  1. Primary Goals: Identifies what the company hopes to achieve (e.g., reducing stress, improving focus, enhancing team collaboration). This helps align the program with the company’s strategic objectives.
  2. Current Challenges: Provides insight into specific pain points (e.g., high turnover, low morale) that the mindfulness program should address.
  3. Previous Programs: Helps avoid redundancy and build on past experiences if the company has already implemented wellness initiatives.

Section 3: Program Preferences

Purpose: To determine the type of mindfulness services the company is interested in and how they would like the program to be delivered.

  1. Type of Services: Offers a range of options (e.g., workshops, virtual sessions, retreats) to cater to different preferences and needs.
  2. Preferred Duration: Helps structure the program timeline, whether it’s a one-time session or an ongoing initiative.
  3. Preferred Time for Sessions: Ensures the program fits into the company’s schedule without disrupting workflow.
  4. Specific Techniques: Allows the company to request particular mindfulness practices (e.g., meditation, breathing exercises) that align with their goals.

Section 4: Employee Engagement

Purpose: To gauge how the company plans to involve employees and ensure high participation rates.

  1. Encouraging Participation: Identifies whether participation will be mandatory, voluntary, or incentivized, which affects program design and communication strategies.
  2. Expected Participation Rate: Helps estimate the scale of the program and resource allocation.
  3. Target Groups: Allows for customization if specific departments or groups (e.g., leadership, customer service) need tailored programs.

Section 5: Logistics and Budget

Purpose: To understand the company’s logistical constraints and financial considerations.

  1. Estimated Budget: Helps tailor the program to the company’s financial capacity and ensures alignment with their expectations.
  2. Logistical Requirements: Identifies any specific needs (e.g., space for on-site sessions, technology for virtual sessions) to ensure smooth implementation.
  3. Timelines: Aligns the program with the company’s schedule, such as quarterly goals or company events.

Section 6: Additional Information

Purpose: To gather any other relevant information that could influence the program design.

  1. Additional Information: Provides a space for the company to share unique aspects of their culture, workforce, or specific needs that may not have been covered in previous sections.
  2. How Did You Hear About Us: Helps the service provider understand which marketing channels are most effective.

Section 7: Next Steps

Purpose: To facilitate the transition from inquiry to action.

  1. Consultation Scheduling: Offers the option for a deeper discussion to refine the program details.
  2. Preferred Method of Contact: Ensures follow-up communication is convenient for the client.

Optional: Additional Services Offered

Purpose: To provide a comprehensive overview of available services, helping the client make informed decisions.

  • Mindfulness Workshops: Short, focused sessions on specific topics like stress management or mindful communication.
  • MBSR Programs: Structured, evidence-based programs for stress reduction.
  • Leadership Training: Tailored programs for executives and managers to enhance leadership skills through mindfulness.
  • Customized Programs: Highly tailored solutions for specific departments or industries.
  • Retreats: Immersive experiences for deeper engagement.
  • App Subscriptions: Digital tools for ongoing mindfulness practice.
  • Ongoing Support: Regular sessions to maintain mindfulness practices.
  • Specific Needs: Programs addressing particular issues like anxiety, chronic pain, or work-life balance.
  • Workplace Integration: Strategies to embed mindfulness into the company culture.
  • Certification: Training employees to become mindfulness instructors, fostering a sustainable mindfulness culture.

Key Benefits of the Intake Form

  1. Customization: The form ensures that the mindfulness program is tailored to the specific needs, goals, and constraints of the client organization.
  2. Clarity: It helps both the service provider and the client align on expectations, objectives, and logistics.
  3. Efficiency: By gathering all necessary information upfront, the form streamlines the planning process and reduces back-and-forth communication.
  4. Engagement: It encourages the client to think critically about their goals and how mindfulness can address their challenges, fostering a sense of ownership and commitment to the program.
  5. Comprehensiveness: The form covers all aspects of program design, from objectives and preferences to logistics and budget, ensuring nothing is overlooked.

How to Use the Intake Form Effectively

  1. For Clients: Take the time to fill out the form thoroughly and thoughtfully. The more detailed your responses, the better the program can be tailored to your needs.
  2. For Service Providers: Use the information gathered to create a customized proposal that addresses the client’s specific goals and challenges. Follow up with a consultation to refine the program details and ensure alignment.

By using this intake form, both the client and the service provider can ensure that the mindfulness program is well-aligned with the company’s needs, leading to a more successful and impactful implementation.


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