TM Interview Form

Title

First name*

Middle name

Last name*

Birth day*

Birth month*

Birth year*

Please enter a number from 1900 to 2022.

Age*

Please enter a number from 0 to 120.

Gender*

TM Centre*

Phone #1*

Phone Number #1*

Phone #2

Phone Number #2

Email*

Most recent education

No. of years attended

Major study

Degrees/Qualifications

Occupation

Employed/Studying

Full time

Part time

Retired

Are you under 18 years of age and living with your parents/caregivers?*

Yes

If Yes - Name of teacher, organisation and/or books

For how long?

Describe experiences and results

What is your present state of mind?

Good

Worried

Tense

Describe

Do you sleep well?

Yes

If No - Please describe

What is your present state of health?

Have you had any prolonged physical condition?

Yes

Such as heart trouble, respiratory trouble, etc

If Yes - Please describe

Have you ever taken any non-prescribed drugs?

Yes

e.g. Marijuana

Other drugs

Have you ever been (or are you now) under the care of a psychiatrist or on any other psycho-therapeutic programme?

Yes

If Yes - When?

What type of programme?

The above information is furnished voluntarily by me in requesting an interview preceding personal instruction with a teacher trained by Maharishi Mahesh Yogi. I wish to begin the unique practice of Transcendental Meditation to further my own personal development. I realise the importance of verification and intellectual understanding of experiences in Transcendental Meditation and its effects in daily life, and therefore I will attend the necessary sessions during the first four days of personal instruction. I further realise the importance of subsequent follow-up sessions which may be necessary to ensure maximum progress.

I agree that all instruction in Transcendental Meditation is for my own personal use, and in order to ensure the effectiveness of the teaching, I agree that I will not directly or indirectly impart or disclose to anyone the mantra I receive or its instructed use. I further agree that I will not disclose, publish, or in any way attempt to instruct or impart the technique of Transcendental Meditation.

Yes, I have read and understood the paragraphs above and agree*

I agree

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TM for Women Aotearoa New Zealand Inc

TRANSCENDENTAL MEDITATION

TM Interview Form