Guided Resilience - Beginning Mindfulness Course - Guided Resilience

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CLIENT INFORMATION FORM 

Mindfulness Course 

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Client Information

 

Name:{"type":"text","name":"Name","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

 

Home Phone: {"type":"text","name":"HomePhone","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

Cell Phone:{"type":"text","name":"cellPhone","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

 

Email:{"type":"text","name":"email","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

 

What is most important to you now that you feel mindfulness and wellness/resilience coaching can support? And why is this so important to you?

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Occupation: {"type":"text","name":"occupation","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

 

Age: {"type":"text","name":"DOB","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","maxlength":100,"placeholder":""}

 

Please describe any experience you have with meditation, prayer, mindfulness, or breathwork:

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Do you have pets? {"type":"checkbox","name":"pets","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"yes\nno"}

 

If yes, please list:{"type":"textarea","name":"pets2","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"maxlength":1000,"placeholder":""}

Education: {"type":"textarea","name":"education","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"maxlength":1000,"placeholder":""}

How would you rate your overall physical health? {"type":"checkbox","name":"physicalHealth","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"Excellent\nGreat\nGood\nFair\nPoor"}

Do you have any sleep problems? {"type":"checkbox","name":"sleep","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"yes\nno"}

Explain: {"type":"textarea","name":"explanation","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"maxlength":1000,"placeholder":""}

Are you dealing with any past or current addictions?

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 Explain:{"type":"textarea","name":"explanation2","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"maxlength":1000,"placeholder":""}

Have you had any issues with Depression, Anxiety, or ADD/ADHD?

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Are you currently seeing a therapist?

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Are you currently taking any medications?

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 please describe...

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Are you usually:{"type":"checkbox","name":"promptness","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","options":"Early\nOn-Time\nRunning Late"}

 

How often do you exercise?

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What do you do for fun?

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 Looking forward to meeting you on Wednesday!

 

Coach Cami

 

 

 

 

 

 

 

 

 

 

 

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You will be billed immediately $70.00.

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