Mindful Meditation Facilitator intake form – Mindful Meditation Australia

Name

First

Last

Email

Lifestyle comfort and difficulty

In this section of the form we are trying to learn about your basic routine and any adjustments we need to make to help you develop a personal mindful meditation practice.

Are you currently navigating any of the following?

Please select all that you are comfortable sharing. If you are navigating challenges but would prefer not to share, please select other.

Other challenges

If you are comfortable sharing the challenge(s) you are navigating please enter it here. If you’d prefer not to share then you can leave it blank.

How full is your cup of energy and compassion right now?

Selected Value: 5

Empty=0/ little to spare/ Full=10

Are you happy with your daily routine?

Yes
No
It’s OK but could use some improvement

than do usually

How would you describe the way you usually wake in the morning?

I usually wake up without an alarm feeling refreshed
I usually wake up with an alarm and feel alert and ready to go
I usually push snooze several times and finally roll out of bed tired
I usually wake up early, but stay in bed for hours scrolling on my phone
I usually wake around 2am, have trouble falling back to sleep, and when I wake a second time I feel tired

How would you describe your usual sleep patterns? (you can choose more than 1)

I usually fall asleep easily and sleep through the night
I usually have trouble falling asleep and waking up
I usually fall asleep easily, but wake many times in the night
I usually don’t sleep long, but it is deep and satisfying
I usually have lots of dreams and feel tired when I wake up
My sleep quality changes each night

How many hours of uninterrupted sleep do you get on most nights?

Which of the following do you do before bed? (You can choose more than one)

Which of the following do you within 30 min of waking up (You can choose more than one)

How do you fuel your body? (You can choose more than one)

I usually eat a balanced diet full of fresh fruits and vegetables, whole grains and protein.
I eat a restrictive diet due to health issues.
I eat a restrictive diet due to personal choice.
I eat a lot of carry-out, fast food, or pre-package foods.
What I eat changes frequently.

How would you describe your support system

I have lots of good friends and family I can ask for support
I have friends and/or family who support me without having to ask
I don’t have many people I can ask for help
I have nobody I feel comfortable asking for support
I don’t need support
I usually refrain from asking for support because I don’t want to burden others

Describe your social life. Check all that apply.

I attend several social gatherings during the week and weekends and I feel energised by them.
I attend several social gatherings during the week and weekends and feel drained by the interactions.
I attend about 1 social gathering a week and I feel energised by attending.
I attend about 1 social gathering a week and I feel drained by the interaction.
My main social interaction is work colleagues at work.
My main social interaction is my partner and/or children.
My main social interaction is my family.
My main social interaction is with my pets.

How hydrated are you usually? (you can choose more than 1)

I drink 8-10 glasses of water
I drink a couple glasses of water
I drink more than 1 cup of coffee
I drink more than 1 caffeinated soft drinks
I drink more than 1 cup of herbal tea
I drink more than 1 cup of caffeinated tea
I often go through the day drinking little
I drink more than 1 caffeine free carbonated beverages

Mindful Meditation Practices

Do you have a mindfulness and/or meditation practice that you enjoy? (you can choose more than one)

If you selected ‘Other’, or if your practice is unique or hard to categorise, please describe it briefly.

Mind type

In this section we are trying to learn how your unique and wonderful mind works. This will help to determine which mindful meditation practices will be easier for you to learn.

Rank how true the following statements are

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I find it easy to complete routine tasks on time without getting distracted.	Strongly DisagreeI find it easy to complete routine tasks on time without getting distracted. Strongly Disagree	DisagreeI find it easy to complete routine tasks on time without getting distracted. Disagree	NeutralI find it easy to complete routine tasks on time without getting distracted. Neutral	AgreeI find it easy to complete routine tasks on time without getting distracted. Agree	Strongly AgreeI find it easy to complete routine tasks on time without getting distracted. Strongly Agree
I often see the connections between concepts that others don't notice	Strongly DisagreeI often see the connections between concepts that others don't notice Strongly Disagree	DisagreeI often see the connections between concepts that others don't notice Disagree	NeutralI often see the connections between concepts that others don't notice Neutral	AgreeI often see the connections between concepts that others don't notice Agree	Strongly AgreeI often see the connections between concepts that others don't notice Strongly Agree
I am generally an energetic person	Strongly DisagreeI am generally an energetic person Strongly Disagree	DisagreeI am generally an energetic person Disagree	NeutralI am generally an energetic person Neutral	AgreeI am generally an energetic person Agree	Strongly AgreeI am generally an energetic person Strongly Agree
I am highly creative compared to the average person	Strongly DisagreeI am highly creative compared to the average person Strongly Disagree	DisagreeI am highly creative compared to the average person Disagree	NeutralI am highly creative compared to the average person Neutral	AgreeI am highly creative compared to the average person Agree	Strongly AgreeI am highly creative compared to the average person Strongly Agree
I find it easy to let go of heightened emotional states like anger or sadness	Strongly DisagreeI find it easy to let go of heightened emotional states like anger or sadness Strongly Disagree	DisagreeI find it easy to let go of heightened emotional states like anger or sadness Disagree	NeutralI find it easy to let go of heightened emotional states like anger or sadness Neutral	AgreeI find it easy to let go of heightened emotional states like anger or sadness Agree	Strongly AgreeI find it easy to let go of heightened emotional states like anger or sadness Strongly Agree
When I want to accomplish something I can see the goal clearly in my mind and make it happen	Strongly DisagreeWhen I want to accomplish something I can see the goal clearly in my mind and make it happen Strongly Disagree	DisagreeWhen I want to accomplish something I can see the goal clearly in my mind and make it happen Disagree	NeutralWhen I want to accomplish something I can see the goal clearly in my mind and make it happen Neutral	AgreeWhen I want to accomplish something I can see the goal clearly in my mind and make it happen Agree	Strongly AgreeWhen I want to accomplish something I can see the goal clearly in my mind and make it happen Strongly Agree
It's easy to keep my mind on one thing at a time even if it's not something exciting	Strongly DisagreeIt's easy to keep my mind on one thing at a time even if it's not something exciting Strongly Disagree	DisagreeIt's easy to keep my mind on one thing at a time even if it's not something exciting Disagree	NeutralIt's easy to keep my mind on one thing at a time even if it's not something exciting Neutral	AgreeIt's easy to keep my mind on one thing at a time even if it's not something exciting Agree	Strongly AgreeIt's easy to keep my mind on one thing at a time even if it's not something exciting Strongly Agree
I often feel a deep sense of inner bliss or contentment for no particular reason	Strongly DisagreeI often feel a deep sense of inner bliss or contentment for no particular reason Strongly Disagree	DisagreeI often feel a deep sense of inner bliss or contentment for no particular reason Disagree	NeutralI often feel a deep sense of inner bliss or contentment for no particular reason Neutral	AgreeI often feel a deep sense of inner bliss or contentment for no particular reason Agree	Strongly AgreeI often feel a deep sense of inner bliss or contentment for no particular reason Strongly Agree

Please add any other additional comments that you think may be relevant to helping you develop a mindful meditation routine