Interview Form

      Name:

      Address:  

      City/State/Zip/Etc:  

      E-mail address:  

      Gender:          Marital status:             Birthdate:                            Today's Date:  

      Emergency contact - name, phone# & email:

      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?
      If yes, name and contact info:

      Are you on any medication and/or have you recently changed medication?  
      If yes, medication name(s):