Meditation/ Neurosculpting ® Intake and Consent form

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This is to get some information before your session so we can customize it for you and also to get your legal consent to meditate together. These questions are just to get more information a sense of what brings you to seek out meditation. Answers are not required except the consent.

Email *

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Do you have any physical injuries or limitations?

What is your experience/ background with Meditation?

What is your primary goal for this session? Intention?

Is there a story or thought that goes through your mind that you would like to work with?

Is there an emotion that you would like to work with?

By typing my name here, it is the same as a signature.

I understand that Meditation is not a cure all, nor a replacement for Professional Therapy. Stefanie Rothert holds no liability for this/ or any future session with Stefanie.

A copy of your responses will be emailed to the address you provided.

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