Essential Screening Questions

Name *

First Name

Last Name

Mobile Number *

Please include the country code

(###)

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1. Are you currently experiencing any of the following? (Check all that apply) *

Active depression or anxiety that interferes with daily life

Recent thoughts of self-harm (within past 6 months)

Major crisis requiring immediate attention (health, family, financial)

Recent psychiatric hospitalization (within past year)

None of the above

2. Do you currently have professional support? (therapist, counselor, psychiatrist, support group) *

Yes (Please describe)

No

Name *

First Name

Last Name

Phone *

Country

(###)

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4. Please confirm by checking All boxes: *

I am joining for my own growth (not to fix someone else)

I understand this is NOT therapy or medical treatment

I understand meditation can surface difficult emotions

I will seek professional help if I experience crisis

5. Can you commit 1.25 hours daily for 88 days? *

Yes, I have identified specific times for practice

No, I cannot commit this time right now

Unsure (please explain):

7. Have you ever had difficult reactions to meditation? (panic, dissociation, increased anxiety) *

No

Yes, (Please briefly describe):

9. Safety Agreement - Check to confirm: [ ] I agree to pause and seek professional help if I experience: *

Thoughts of self-harm

Inability to manage daily responsibilities

Persistent confusion or disconnection from reality

Return to harmful substance use

May we contact you if needed?

Yes - Phone

Yes - Email is fine

No