Form Fill Mindfulness | It's A Nu Dai Community Lounge

Full Name*

Preferred Name (if different)

Pronouns

Email Address*

Phone Number*

Preferred Method of Contact: (Email, Phone, Video Call, Other)*

How did you hear about our guided mindfulness sessions?

Have you practiced meditation or mindfulness before?

Yes, regularly

Yes, but only occasionally

No, I’m a beginner

What are your main reasons for seeking guided mindfulness sessions? (Select all that apply)

🌿 Reduce stress & anxiety

🧘 Improve focus & mental clarity

❤️ Emotional healing & self-compassion

😴 Improve sleep quality

🌟 Spiritual growth & self-discovery

💆 Support for work-life balance

Other

If other, please specify

Are there any specific challenges or concerns you hope mindfulness can help with?

On a scale of 1-10, how would you rate your current level of stress? (1 = No Stress, 10 = Extremely Stressed)

What type of mindfulness practices are you most interested in?*

Meditation

Breathing exercises

Body scan techniques

Mindful movement (e.g., yoga)

Guided visualization

Journaling for mindfulness

Eating mindfully

Would you like to incorporate any of the following into your sessions?

🎵 Guided meditation with music or nature sounds

🔥 Breathwork exercises

📝 Journaling prompts

🧘 Body scan or movement-based mindfulness

What length of mindfulness session do you prefer?*

10-15 minutes

20-30 minutes

45-60 minutes

Would you prefer

🧑‍🤝‍🧑 One-on-one guided mindfulness

👥 Group mindfulness sessions

🖥️ Virtual (Online) sessions

🏡 In-person (If applicable)

How often do you experience stress or anxiety?

Daily

A few times a week

Occasionally

Rarely

Do you have any health conditions (physical or mental) that we should be aware of before guiding your mindfulness?*

Do you currently use any other relaxation techniques? (e.g., yoga, breathwork, journaling, therapy, etc.)

What days/times work best for your mindfulness sessions?

How committed are you to practicing mindfulness regularly? (1 = Not Ready, 10 = Fully Committed)

What would a successful mindfulness practice look like for you?

Is there anything else you’d like to share about your mindfulness goals or needs?

Welcome!