Men’s Mindset Meditation Meetup Date MM DD YYYY Name * First Name Last Name Email * Phone * (###) ### #### Current Mindset Status In general, I am comfortable expressing my thoughts Strongly Disagree Disagree Neutral Agree Strongly Agree People in my life think I am an asshole Strongly Disagree Disagree Neutral Agree Strongly Agree I struggle to express my feelings Strongly Disagree Disagree Neutral Agree Strongly Agree It's hard for me to identify what I am feeling Strongly Disagree Disagree Neutral Agree Strongly Agree People don't understand me Strongly Disagree Disagree Neutral Agree Strongly Agree Relationship(s) in my life could improve Strongly Disagree Disagree Neutral Agree Strongly Agree I find it hard to express myself without getting angry Strongly Disagree Disagree Neutral Agree Strongly Agree I have experienced trauma in my life Strongly Disagree Disagree Neutral Agree Strongly Agree I find it easy to walk away from arguments Strongly Disagree Disagree Neutral Agree Strongly Agree I don't like to apologize (even when I am wrong) Strongly Disagree Disagree Neutral Agree Strongly Agree I am satisfied in my career Strongly Disagree Disagree Neutral Agree Strongly Agree I have a good support system in my life Strongly Disagree Disagree Neutral Agree Strongly Agree Which Men's Mindset Meditation Meetup Format are you interested in attending? * We are offering several options for in-person and online. Start Dates will depend on level of interest. In-Person (Sanford, NC)- Wednesday's 6pm-8pm- Start Date- 02.01.2023 Online- Tuesdays 4pm-6pm- Start Date: 02.07.2023 Do you have any prior experience with meditation or hypnosis? Yes No I am not sure Do you agree to keep all information shared within the group confidential and private? * This is paramount for our group. Every participant must agree to keep everything said in the group sessions completely confidential. Exceptions to this include mandatory child abuse reporting and suicide/homicide risk must be reported to authorities per our Code of Ethics. Yes, I agree No, I don't agree I have some questions before I agree Thank you!