Name
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First Name
Last Name
Email
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Phone
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Preferred Pronouns
Let's get started! Please briefly tell me about yourself!
What are some of your passions? What gets you excited about life? When do you feel the most alive? How do you spend your time? How do you wish you spent your time? What are some of your core values in life? Go into as much or as little detail as you wish!
Why are you seeking mindfulness & movement support?
What do you hope to shift or alter through this process? In a perfect world, what would you take-away from a movement & mindfulness plan? What are your hopes and dreams (related or unrelated to movement & mindfulness)?
Past Movement Experience
How do you feel about exercise in general? What has exercise meant to you in the past? Feel free to list general emotions, stories, or anything that feels relevant to share.
Past Mindfulness Experience
How do you feel about mindfulness and meditation in general? What stories or ideas come up when you hear the word "mindfulness"? In a perfect world, how would you practice mindfulness & meditation? Why? What do you hope to come away with, from such a practice?
Exercise Space Options Available to Me
Check any that currently apply
If other, please elaborate here
Available Mindfulness Space & Tools
*
Available Time for Meditation Practice
I am willing to try....
Client Log Accessibility
We use Google Docs for daily accountability, workout & mindfulness plans, support & communication.
How did you find Anna & what interests you about working with her?
What is your current exercise routine? What is your current favorite form of movement?
Past or desired movement-style if you don’t currently have one. (Ex) This could be anything - walking, dance, breath work, yoga, surfing, backpacking, etc.)
Where do you most often get “stuck” with exercise?
Ex) “not enough time,” “I’ll never be able to (fill in blank) so why bother,” “I don’t know what exercises to do,” or mid-routine “this routine sucks!” etc. Those are some ideas. There is no right answer!
Fast forward six months, or even 6 years from now… What would you like to see has shifted in your life and/or to your relationship to exercise?
(This can be physically, judgements about yourself, your attitude, etc. Sketch it, speak it out-loud to your cat or imaginary cat, write it free-flow… What ever process works best for you. Then jot down a couple words or sentences here.)
Do you have equipment for exercise you like to use that’s available on a weekly or daily basis? What is your favorite equipment (if relevant)? Do you have the means to find or buy equipment if recommended (in the $10-40 range. This is absolutely not a requirement)?
What does a typical day look like for you? Do you have a consistent daily routine/schedule?
Feel free to describe a typical day or week in your life. Draw out a calendar or your stick-figure-self performing your typical week, if that’s a helpful organizational tool for you & how your brain works.
Do you like practicing meditation or exercising with friends & groups?
Do you prefer solo meditation & movement? Or some combination of the two? Have you had more success or less success one with one version or the other in the past?
Do you have any injuries, doctor recommendations, or accessibility needs Anna should be aware of?
What is something you adore?
This can be something you “do,” like visiting a special location in the world, eating ice cream, dancing, backpacking, playing video games, reading certain books… Those are just some ideas, really this can be anything! What is something that really GETS you in your zone or you feel a connection to in life? Maybe this is a past childhood feeling or memory you can really feel, maybe this is something you do daily. Draw, write free-flow, or jot down a couple ideas.
Is there anything you would like to be sure Anna considers including or excluding into your program?
What questions, concerns, expectations, or exercise requests do you have for Anna before starting?
