Private Session Intake Form

Blind Spot Wellness - Alyssa Johnson - Duluth, Minnesota - Yoga, Mindfulness and Holistic Nutrition Sessions



Please take 20-40 minutes to fill out the following form. This will allow me to understand your intentions and commitment to starting a private session mindfulness practice. This is the first step of your practice (reflecting), please take your time and fill out to the best of your ability.

Name *
Birthday *
What areas are you most interested in exploring, check all that apply. *
What do you hope to gain from this practice? What do you hope to let go of?
The effects of mindfulness are strongly dependent on the amount of practice. Mindfulness is a participatory medicine, meaning what you put in you get out. This is different than being a passive recipient (i.e. Massage Therapy, etc.). When starting a mindfulness practice you are starting a journey towards self-development, self-discovery, learning and healing. With that said, often things seem to get 'worse' before they get 'better'. As we become more aware of our habits and thought patterns we can begin to notice aspects of ourselves we never knew were there. Are you willing to work through the challenges?
Please indicate which symptoms you experience on a daily or weekly occurrence. *
Do you currently have any physical ailments? Are you on any medications? Do you have a past or current history of depression, anxiety, eating disorder, bipolar disorder, obsessive-compulsive disorder, schizophrenia, ADHD or any other mental health concern? If yes, please specify
Rate how well each health and wellbeing statement describes you. *
Rate how well each health and wellbeing statement describes you.
Fitness: I feel healthy and am happy with the physical condition I'm in.
Nutrition: My diet is where I want it.
Sleep: I get a straight 7-8 hours of sleep every night.
The amount of stress I'm under is about average and I manage it well.
Body Image: When I look in the mirror I feel content and grateful for the body I have.
Self Care: I regularly take "me time" to relax and take care of myself.
Alcohol or other substances: I have a healthy relationship to alcohol/substances and practice moderation.
Pain: My body feels good most of the time and I rarely have aches and pains.
Energy: I have balanced energy throughout the day and rarely feel lethargic.
Mindfulness: I am aware of my thoughts and actions and typically feel nonjudgmental towards myself.
Relationships: My relationships are strong and supportive.
Friends: I have people in my life who I trust, care about, have fun with and can be myself around.
Family: I love and respect my family and know they love and respect me.
Finances: I spend within my means and feel confident in my budgeting skills.
Career: The work I do uses my strengths and suits me well.
Stay reasonable, what fits in your schedule. Once a week, biweekly, etc. For one hour, 1.5 hours, etc. Will this be ongoing, 8 week increments, etc? Things will change, but please provide your intentions.
It could be anything: dance, hiking, biking, painting - what is a passion of yours that fills you up.