Before answering these questions, please read our Trauma Advisory page. Then answer the following questions. Your answers will help your teacher better serve you during the course.

If you have any questions, please contact the course teacher directly by using this form. Thank you!

Participant Questionnaire

Name *

First Name

Last Name

What course or event will you be attending? *

Trauma Advisory *

I have read the trauma advisory and realize there is a chance that meditation may trigger the memories of unresolved trauma in me. Knowing this, I take this course at my own risk and will minimize my risks by following the risk reduction guidelines explained in the trauma advisory.

I have read the trauma advisory, have some concerns, and would like to speak with the teacher directly.

On the trauma advisory, did you answer yes to any of the flashback risk factor questions? *

Yes.

No.

Would rather not say.

Why are you attending this course or event? What do you hope to get out of it? *

Do you have any specific concerns or problems in your life that you hope this class will help you address? What are they?

Overall, how much time and energy have you spent addressing your concerns mentioned in the previous questions?

None

Minimal amount

Fair amount

Significant amount

Maximum amount

Overall, how successful have your efforts been in addressing your concerns?

Not at all

Minimal

Fair amount

Significant

Completely

How much of your disappointment and unhappiness do you see as being self-inflicted?

None of it

Minimal amount

Fair amount

Significant amount

All of it

Will you be Zooming in on a computer, tablet, or phone? (It’s best to use a computer) *

Computer

Tablet

Phone

Other

How familiar are you with Zoom? *

I have never used it.

I’ve used it, but am not comfortable with it.

I am comfortable with using Zoom.

Which of the following skills are you comfortable doing on Zoom? Check all that apply. *

Changing my name.

Switching between “speaker view” and “gallery view.”

Posting a message into chat.

Muting and unmuting myself.

Starting and stopping my video.

None of the above.

How important is religion or spirituality in your life?

Religion and spirituality offend me

Not at all

Slightly

Somewhat

Very

My Top Priority

How do you describe or define your religious, spiritual, or philosophical beliefs? (i.e. Christian, Jewish, Islam, Hindu, Free Thinker, Humanist, Agnostic, etc.)

On average, how many days a week do you meditate? *

If you currently have a meditation practice, what does it look like? (How long do you meditate per sitting? What style or styles of meditation do you do? Who are your teachers, or who taught you this meditation? Etc.)

Thank you for completing this questionnaire. We wish you boundless love, peace, joy, and ease.

Tagged: Mindfulness fundamentals