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Harmonic Mind Intake Form
Please fill out the following form. Answer the questions with as much detail as is necessary to be thorough. This form will help us to better understand and serve you. It will also help to provide you with a reference point so that you can track any changes that occurred by the end of program. Please take your time and be as open and vulnerable as you are able. Your private information will be held in love and strict confidentiality.
Date of Birth
1. What inspired you to take this course?
2. What are your goals for your state training practice?
3. What is your previous experience with mediation or state training practices? Have you ever used binaural beat programs or a particular meditation technique? Please describe.
4. Do you have any physical or mental health concerns that might be a factor in this course? If so please describe.
Multiple Choice: Select the one description that best fits your perspective. Do your best to choose how you identify as a daily baseline rather how you feel in peak states or moments of uncommon clarity. If you relate to more than one answer choose the one that feels the most familiar and comprehensible.
I seek truths in individualistic terms; scientific; experimental and verifiable by clear evidence. The world is a well-oiled machine with natural laws that can be learned, mastered and managed to achieve specific goals.
I cherish the Earth and the well-being of all people. Hierarchy is the root cause of oppression and should be dismantled to establish equality for all. Decisions should be made in a consensus agreement with all concerned parties with the reconciliation of conflicts as the highest goal.
The universe is a living super-organism made of complex multivalent patterns and processes that guide all things toward a transcendent goal. I see all creatures, beings things and events as aspects of its body-mind-soul and aspire to an intimacy with and understanding of its nature as the highest purpose for my life.
There is a universal order based on living systems, not external rules or bonds. I view all perspectives and orientations as having some essential part of the larger picture of reality. The world is made of many layers of network interactions, each playing an essential role to support a unification of all levels.
I believe in the goodness of natural hierarchies thus egalitarianism is balanced a natural meritocracy. Competency take precedence over group consensus, power and status. The world is made up of many different realities that interview to make a complex and dynamic whole.
None of these answers are quite right for me
5. How do you see the world? Our world view is made up of attitudes, beliefs and values. It describes how you see the world and what interpretations you give to life experiences. It may include your political, philosophical or religious perspectives. Please include as much information as is necessary to feel that your unique perspective has been represented. Note: If you have trouble identifying or describing your world-view, that’s okay, just share whatever comes up for you when considering this question.
6. Please describe your level of satisfaction with your life. Do you feel aligned with a sense of purpose or meaning? Are there significant challenges that feel overwhelming, or do you generally feel at ease?
7. What do you experience as the most significant challenge you have to face in this current chapter of your life?
8. What inner resources or skills do you feel would be the most beneficial for bringing you to your next level of personal contentment?
9. Are there any habits, either mental or physical that you would like change? please describe.
10. Do you participate in a religious or spiritual tradition? Or do you have a non-traditional spiritual practice? Please describe.
11. Have you had any spiritual experiences, experienced mystical states or other experiences that you would classify as non-ordinary? Please describe.
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