Emotional Cleanse (Chitta Sudhi)

Mastermind Balance – Balance Your Emotions, Take Conscious Action

Workshop Facilitator: Bhawna Mittal

All information shared in this form will remain strictly confidential and will only be used to support your well-being during this five-week journey.

PARTICIPANT INFORMATION

Full name

Date of birth

Phone number

Email address

Emergency contact name & phone

Occupation

SECTION 1: EMOTIONAL AWARENESS

What emotions are you currently experiencing most frequently?

How long have you been holding or experiencing these emotions?

Do you feel there is a specific situation, memory, or experience connected to these emotions? Please describe.

How do these emotions influence your daily actions, decisions, or relationships?

SECTION 2: PHYSICAL HEALTH & EMOTIONAL CONNECTION

How do you feel physically when you are holding these emotions?

Are there specific physical disturbances (such as tension, digestive issues, sleep changes, fatigue, headaches, etc.) that arise during emotional imbalance? Please describe.

How would you describe your current physical energy and overall health?

How would you describe your current sleep patterns and quality?

How has your appetite been lately? Any changes in eating patterns or food preferences?

SECTION 3: MEDICAL & SUPPLEMENT INFORMATION

Are you currently taking any medications? If yes, please specify.

Are you currently taking any supplements or herbal products? If yes, please list them and indicate how long you have been taking them.

Do you have any diagnosed physical or mental health conditions that we should be aware of?

SECTION 4: SELF-AWARENESS & ACTION

What actions or decisions do you feel you have been avoiding?

What area of your life currently feels most out of balance?

At the end of these five weeks, what would emotional balance look like for you?

SECTION 5: OPTIONAL PERSONAL STORY

On a scale of 0-10, rate your emotional or mental health symptoms individually. This will help us to monitor your progress at the end of program.

If you would like to share a short story about your struggles, emotional challenges, or the reason you are holding these emotions, please write below. This will help us create a supportive plan aligned with your well-being.

Is there anything else you would like to share that might help us support you better during this workshop?

CONFIDENTIALITY AGREEMENT

All information shared in this intake form and throughout the Master Your Mind workshop (March 1 – April 5) will remain strictly confidential and will not be shared with any third party without your written consent, except where required by law.

By providing your signature below, you acknowledge that you understand and agree to this confidentiality commitment.

WORKSHOP WAIVER & LIABILITY RELEASE

This workshop is an educational and self-development program focused on emotional balance, mindfulness practices, yoga-based techniques, breathwork, and lifestyle awareness.

I understand that this workshop does not replace medical, psychological, or psychiatric care.
I acknowledge that participation is voluntary.
I accept full responsibility for my physical and emotional well-being during this program.
I understand that emotional release may occur during practices.
I agree to inform the facilitator if I experience distress requiring professional referral.
I release the facilitator from liability for any injury or emotional discomfort arising from participation, except in cases of gross negligence.

Participant name (print)

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Date

Program payment

$100