1-on-1 privateMindfulness CoachingPre-class surveyIt would take about 5-10 minutes to complete this step.Thanks for your patience.1-on-1 Mindfulness Coaching pre-class surveyThank you for your interest in 1-on-1 Mindfulness Coaching classes. In order to help us customize a training plan for you, please spend a few minutes to answer the following questions. NOTE: Due to the personal nature of these questions, please be assured that the completed forms are kept in strict confidence.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone no. (Preferred) *Phone no. (2nd)Gender *Please choose your answerFemaleMaleDate of BirthOccupation / Profession *What is your intention for attending 1-on-1 coaching sessions? *How much experience do you have with mindfulness meditation or other forms of meditation? *Which of the following area(s) do you feel interested to cultivate / deepen? *Focus & ConcentrationBodily AwarenessEmotional balanceDealing with pain & difficultiesLiving with joy & presenceSelf-CompassionCourage and fearlessnessHealthy habit changeOthers (please specify in Remark section)Referrer (If applicable)FirstLastPlease choose your preferred class time *Weekday afternoonWeekday eveningWeekend morningWeekend afternoonPlease choose your preferred class location *Mongkok / Yau Ma Tei / Tsim Sha TsuiCentral / Sheung Wan / Sai Ying PunKwun Tong / Kowloon BaySha Tin / Tai PoAt your venue (please specify in Remark section)Remark for additional information you want to let us knowEMAIL/TEXT MESSAGE COMMUNICATION CONSENT: As a participant in the 1-on-1 private mindfulness coaching training, you may wish to communicate with your instructor via email and/or text message on occasion. In order to ensure your privacy, we request that you give written permission for this form of correspondence. Please check one of the following options: *I give my permission to communicate via email and/or text with my instructor about any aspect of my training experience.I do NOT give permission to communicate via email and/or text.PhoneSubmit
