Interview Form

Name:

Address:  

City/State/Zip/Etc:  

E-mail address:  

Gender:    Marital status: Birthdate:    Today's Date:  

Emergency contact - name, phone# & email:

Occupation:  

In what year did you start meditating:  

Previous Retreat Experience including dates, length of retreat, teacher(s):  

 

 

 

Current Meditation Practice including frequency and method(s):  

 

 



 

Have you ever experienced strong pleasure and/or joy (Piti/Sukka) while meditating?
If so please describe:  



 

 

 

Are you under the care of a doctor or a therapist?
If yes, name and contact info:

Are you on any medication and/or have you recently changed medication?  
If yes, medication name(s):