First Name: Last Name: Occupation: Birth-Date: Age:
Country: Zip/Post Code:
Phone: Fax #:
Single, Married, or Committed Relationship?
Ages of Children? Are they living with you?
Please list any Hobbies, Sports, or Other Activities that You Enjoy.
Education Completed: Religion Raised in:
Spouse's or Companion's religious upbringing?
Do you Currently Practice a Religion or Spirituality?
If yes, how would you Describe it?
Companion's or Spouse's spiritual practice:
Do you have any Meditation Experience?
Kind of Meditation You Practice?
What Kind of Group:
Are you taking any prescribed medications?
Please list medications & reasons for taking them:
Drug or Alcohol Use? Please Specify.
Have you been in Counseling Before?
If Yes, Please Specify Why:
What Areas Below Touch upon Your Immediate Concerns:
Psychological: Purpose: Interpersonal: Meaning:
Emotional: Creativity: Spiritual: Faith: Health:
Meditation: Sexuality: Breathing: Finances:
Life Stress: Compassion: Values:
Self-Esteem: Not-Knowing: Inner Peace:
Fear: Confidence: Anxiety: Joyfulness:
Share with me three categories that are
the most important to you Now and why: