Beginning Meditation Group Prospective Member Information
Date
Date of Birth
First Name
Last Name
Address ___
City ____________
______________________________
_________________
State ___
Primary Phone
__
Apt #
Zip
Ok to leave a voice message?
 Yes
 No
Ok to send messages via e-mail?  Yes  No
Email Address ________________________________
What would you like to gain from participation in the meditation group?
HISTORY
Have you ever had any treatment for mental health issues?
 Yes
 No
If yes, what kind of treatment did you get (counseling, medication, etc.)?
When?
For how long?
For what?
Are you currently (or in the recent past) taking any prescription medications?
 Yes
 No
If yes, what are/were you taking?
Are you aware of any mental illness in your family?
 Yes
 No
If yes, who and what are you aware of?
CURRENT STATUS
Do you drink alcohol?
 Yes
 No
If yes, how many times per week do you drink and approximately how many drinks per sitting?
How frequently do you drink to excess or blackout?
Do you use any other recreational drugs?
 Yes
 No
If yes, what do you use and how often?
Do you ever notice feeling preoccupied with what you eat or how food affects your body?
 Yes
 No
If yes, describe what you experience:
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 Yes
Have you ever been charged with a crime, arrested or convicted?
 No
 Yes
Are you concerned about your performance or level of functioning at work or in school?
 No
If yes, please describe your concerns:
Have you ever had an experience in which you thought you were at risk of losing your life?
CURRENT SYMPTOMS
How is your sleep?
 No problems
 Not enough
 Trouble getting up
 Nightmares
 Yes  No
 Too much sleep
What have you noticed about your appetite?
 No problems
 No interest
 Increased appetite
 Carbohydrate craving
What has you energy level been like?
 Normal
 Increased
 Up and down
 Low
How is your concentration?
 Normal
 Somewhat difficult
 Poor
 Terrible
How would you describe your memory?
 Good
 Some difficulty remembering
 Poor
Have you been feeling depressed or sad?
 All the time
 Most days
 Some days
 Not at all
Have you had thoughts about hurting yourself?
 All the time
 Most days
 Some days
 Not at all
Have you ever attempted suicide in the past?
 Yes
 No
If yes, what happened and when?
Have you had problems with anxiety?
 Panic attacks
 All the time
Have you felt angry and/or irritable?
 All the time
 Most days
 Most days
 Some days
 Some days
 Not at all
 Not at all
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