Intake Questionaire Intake Questionnaire Please complete the following questionnaire at least 48 hours before your appointment. The more information you provide in the questionnaire, the better. It helps me to give you the most beneficial session that I can. Your time is valuable. Your information is automatically sent to my email. Providing the information prior to your session will allow me to better specify the program to your needs. After you fill out your form, make sure to prepare for your session by following the suggestions below. For session costs, please see Pricing. Payment is due on the same day of our session. I accept cash or credit card. Please note: I respectfully request at least 48-hour notice for cancellations or rescheduling of appointments. There is a 50% “no show” fee. Jason Gorenstein Meditation and Yoga Questionnaire After you fill out your form, make sure to prepare for your session by visiting the FAQ.Name First Last Email PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Section BreakWho are you interested in seeking service for? Private Group Corporate Phone SkypeHave you ever done yoga/meditation before?YesNoWhat is the reason that you are seeking yoga/meditation in your life?Is that a specific aspect of Meditation or Yoga that you would like to focus on? Relaxing Calming Strengthening Stretching Empowering Focusing Clarity Ease Presence Commitment Dedication Integrity Practice Stress Reduction Flexibility Strength Clarity Ease Focusing Presence Letting go Diet Chakras Chanting Mudras Sanskrit Self-Inquiry Bhandas (Energy locks) Naudis (Cleansing Practices) Surrender Thought PatternsDo you have any physical conditions that I should know about? Chest Pain Back Pain Neck Pain Sciatica Insomnia Depression High Blood Pressure Hypotension Hypertension Asthma Addiction Anxiety Vertigo Eating Disorder Pregnancy Headaches Weakness Pain OtherIf so, what trimester?If so, where and what degree is your pain?If other, please specify:Will you be needing any of the following? Yoga Mat Yoga Blocks Yoga Straps Yoga Blankets Yoga BolsterAre you interested in receiving visual or audio recordings of your sessions?YesNoNot sure