I am furnishing this information as a step toward learning Effortless Meditation™. The information is strictly confidential and will not be disclosed to anyone. Completing this form does not obligate me to take the meditation course.
Interview Date*
MM slash DD slash YYYY
Name*
First Last
Age*
Please enter a number from 00 to 99.
Birth Date*
MM slash DD slash YYYY
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Email*
Occupation
Home Phone
Cell Phone
Have you ever practiced another form of meditation?*
- Yes
- No
How would you describe your health*
- Excellent
- Good
- Fair
Are you presently involved in psychotherapy/counseling?*
- Yes
- No
If yes, what is the frequency of your visits?*
Please list any benefits you'd like to gain from the practice of Effortless Meditation.
Benefit #1
Benefit #2
Benefit #3
I understand that there are three days of instruction immediately following the first day. I understand the importance of these sessions and agree to attend all four days. I respect the confidential aspects of this meditation program, and understand that I am learning this technique of meditation for my own personal use. In order to ensure the effectiveness of the Effortless Meditation™ program, I agree not to teach, or impart the mantra/sound I receive, or the technique that I learn to others.
Signature*