Name

First Name

Last Name

Date of Birth

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear about my work?

Have you meditated before? If yes, please describe.

Have you practiced breathwork? Please describe.

Do you or your family have a history of mental illness?

Are you on any medication? Please explain.

What do you hope to get out of our sessions together?

Anything else you would like me to know?

On a scale of 1 - 10 ( with 1=Never, 10=All the time) please rate how often in daily life you experience the following:

Anxiety

Overwhelm

Strong emotions

Restricting food

Binge eating

Reactivity

Depression

Fear