Address:
City/State/Zip/Etc:
E-mail address:
Marital status:
Occupation:
In what year did you start meditating:
Previous Retreat Experience including dates, length of retreat, teacher(s):
Current Meditation Practice including frequency and method(s):
Have you ever experienced strong pleasure and/or joy (Piti/Sukka) while meditating - if so please describe:
Are you under the care of a doctor or a therapist?
Are you on any medication and/or have you recently changed medication?
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/ Revised Aug 7 '02