Mindfulness Intake Form – Myofascial Release Center

BASIC INFORMATION

Today's Date *

Email *

First Name *

Last Name *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Employer *

Occupation *

Date of Birth *

Age *

Gender *

M
F
Other

Marital Status *

Single
Married
Divorced
Widowed

Number of Children *

Emergency Contact Name *

Emergency Contact Phone Number *

YOUR ISSUE

What's are the emotional/physical issue(s) that you're ready for me to help you resolve? *

How big of an issue is this in your life? *

Major
Serious
Moderate
Minor

What areas of your life does this involve? *

Do you consider this to be more of a problem, or a goal? *

Problem
Goal

Select any of the following that applies to your issue: *

Do you want to resolve it, or do you 'want to want' to resolve it? *

I want to resolve it
I 'want to want' to resolve it

What has this issue cost you so far in your life (time, money, suffering, lost opportunities, sacrifice, etc.) *

A lot
A little
Not much
Nothing

What has been this issue's biggest cost to you? *

If left unresolved, what could th is issue end up costing you over the next 10 years? *

A lot
A little
Not much
Nothing

Are you looking for a quick fix, or are you ready to sincerely commit to doing what it takes to resolve this? *

Looking for a quick fix
Ready to sincerely commit to doing what it takes

How committed are you to resolving this? *

100%
75%
50%
25%

What have you previously invested in to help you with this? *

What characteristic(s) are most important to you in a coach or therapist? *

How would you rate your ability to follow instructions? *

Above Average
Average
Below Average

MORE ABOUT YOU

What's most important to you about resolving this issue? *

What are your main strengths? *

What are your main limitations? *

List 5 or more of your most meaningful accomplishments: *

HEALTH & FITNESS

Primary Physician name & number *

Please list any current treatment being received from any health care providers: *

Please list any current medications and dosages: *

How often do you exercise? *

What type(s) of exercise do you engage in? *

Hours of sleep required: *

What is your normal bedtime? *

Do you have difficulty falling asleep? *

Yes
No
Sometimes

Do you have difficulty staying asleep? *

Yes
No
Sometimes

Which of the following physical complaints currently apply to you? *

Which of the following emotional complaints currently apply to you? *

RECENT LIFE CHANGES

Health Changes *

An illness or injury which was very serious
An illness or injury which was moderately severe
An illness or injury which was less serious
Other

Home/Family Changes *

Financial Changes *

Work Changes *

CANCELLATION POLICY

We have a 24 hour cancellation / rescheduling policy: Cancelled, changed or missed appointments with less than 24 hours notice will result in the loss of that session (value $125). a fee of $70. This policy is in place out of respect for our therapists, and our clients, because an appointment cancelled with less than 24 hours notice results in a time slot that is difficult to fill, and giving last minute notice or no notice at all prevents others from being able to schedule into that time slot.Thank you for your understanding and cooperation.

I understand and agree to the policies described above: *