Customized meditation program
Exit this survey >>
1. CUSTOMIZED MEDITATION PROGRAM
The purpose of this form is to assist you in developing a personally customized meditation program which best supports you. As you further develop in your practice this program may change as time progresses. It is recommended that this program is reviewed at least every 3 months. All information provided here is strictly confidential. Multiple answers may be selected by circling or highlighting the letter of your choice.
You may return the form via email, in person or through the mail to:
Empowerment Healing - Unit 4, 47a Golden avenue, Chelsea VIC 3196
If you have any concerns you may contact the me on 0407 992 205 or at adam@empowermenthealing.com. Alternatively you may wish to check out the website at www.empowermenthealing.com
Light and Love,
Adam Teeuwsen
1
. Briefly describe each of the following areas in your life. This is just to get an idea of who you are and may provide clues as to how to best develop the program. Such things may include your physical health, work life, what you do at home, who your family and friends are, how you spend your spare time, your interaction with the local community, financial commitments, do you have any spiritual/religious practices, and so on. The more you tell us the better developed this program can be. However, please only describe that which you feel comfortable in doing, there is no pressure. If you can’t think of anything, leave it and go onto the next area.
Briefly describe each of the following areas in your life. This is just to get an idea of who you are and may provide clues as to how to best develop the program. Such things may include your physical health, work life, what you do at home, who your family and friends are, how you spend your spare time, your interaction with the local community, financial commitments, do you have any spiritual/religious practices, and so on. The more you tell us the better developed this program can be. However, please only describe that which you feel comfortable in doing, there is no pressure. If you can’t think of anything, leave it and go onto the next area.
2
. 1. What is your understanding of meditation?
1. What is your understanding of meditation?
None
A little
Moderate
High
Professional
3
. What do you hope to get out of meditation program? Whats your purpose for doing it?
What do you hope to get out of meditation program? Whats your purpose for doing it?
Reduce stress and anxiety
Improve concentration and memory
Improve performance at work and/or study
Increased staminy and vitality. More energy
Develop a more positive outlook on life
Develop a more positive attitude towards others
General wellbeing
Learn ways in how to help myself and/or others
Reduce the risk or symptoms of physical illness
All of the above
Not sure
Other (please specify)
4
. Is there any type of meditation that you prefer?
Is there any type of meditation that you prefer?
Counting the breath
Problem solving, resolution conflict
Developing compassion towards others
9 pointed breath
Chanting mantras
Colour
Dance therapy
Past reflection
Chakra balancing
Psychic protection
Connecting with higher self
Walking
Tai chi
Yoga
Pilates
Qi gong
Connecting with nature
Channeling
Watching mandalas
Prayer
Self affirmations
White light
Tree root
Sensory
Watching the observer
Manifesting your dreams
Not sure
All of the above
Other (please specify)
5
. What mode of meditation best suits you?
What mode of meditation best suits you?
Passive (such as sitting, breathing)
Active (such as walking, yoga)
No preference
6
. Anything else that should be added to this survey? Any comments or suggestions in how this survey could be improved?
Anything else that should be added to this survey? Any comments or suggestions in how this survey could be improved?
7
. Whats days are most suitable for you to meditate? (may choose multiple)
Whats days are most suitable for you to meditate? (may choose multiple)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
8
. What times are most suitable for you to meditate? (may choose multiple)
What times are most suitable for you to meditate? (may choose multiple)
Morning
Afternoon
Night
Doesn’t bother me
9
. What location/s around Melbourne would be most suitable for you to meditate? (may choose multiple)
What location/s around Melbourne would be most suitable for you to meditate? (may choose multiple)
Southern
Northern
Eastern
Western
City
Rural (outside of melbourne)
10
. What aids would you like to use while meditating?
What aids would you like to use while meditating?
Incense, perfumes
Furniture (cushions, pillows, tables, chairs, blankets)
Music (soft background)
Visual decorations (art pieces, mandalas, posters)
Other
All of the above
Powered by
SurveyMonkey
Create your own
free online survey
now!
Javascript is required for this site to function, please enable.