HeartSpace Circles by Om Mani

Community Registration Form

Welcome and thank you for your interest in joining a HeartSpace Circle: a free monthly gathering for reflection, gentle movement, and mindful connection.

Please take a moment to share a few details below.

All information is kept private and is used only for event coordination and communication.

First name

Last name

Email

Phone

Age Group

16–25 (Youth Circle)

60+ (Elder Circle)

General Public

Please mention the name of the source, if this is a word of mouth or a referral

For which circle are you signing up for? Please mention the date.

Please take a few moments to reflect on what brings you here today. There are no right or wrong answers: just what feels true for you.

What draws you to this Circle, or what do you hope to experience?

Have you worked with a Coach, Therapist or an Energy Practitioner before?

Yes

No

Prefer not to say

If yes, what approaches or practices have been most helpful for you?

Have you ever experienced a Cacao ceremony before?

Yes

No

Prefer not to answer

Cacao is optional and offered in small, mindful servings

Do you have any sensitivities or medical conditions (such as caffeine sensitivity, heart conditions, or pregnancy) that we should know about before serving ceremonial cacao?

(Cacao contains natural theobromine, a gentle, heart-opening stimulant similar to dark chocolate.)

Do you or your group have any accessibility needs or mobility considerations?

e.g. prefer chair seating, low lighting, etc.

Are there any sensitivities (scents, sounds, etc.) we should know about?

Is there anything else you’d like to share with Sanskriti before the Circle?

HeartSpace Circles are reflective, community-based gatherings, not therapy or clinical support groups.

Participation is voluntary; you are free to share or simply observe.

Confidentiality and mutual respect are essential to maintaining a safe space.

Photos may be taken during the Circle and may be used for Om Mani’s promotional or social media purposes. Please choose any of the following:

I consent to appear in photos.

I prefer not to be photographed.