Name *

First Name

Last Name

Please indicate which services you are interested in at this time. *

Self+Care Coaching

Meditation Mentoring

I'm unsure and would like to discuss my options.

Do you currently have a meditation practice or have you ever meditated before? *

yes

no

Have you ever had or been treated for a psychological condition such as PTSD, depression, eating disorder, drug/alcohol addiction, anxiety disorder, psychosis, schizophrenia, mania or any other psychological condition? *

yes

no

I'd rather not say

If yes, are you currently seeing a therapist or psychiatrist?

yes

no

I'd rather not say