Pre-Workshop Questionnaire for Adults

    Name:

    Email:

    Cell #:

    Age:

    Occupation:

    How did you hear about us?

    Rate the following as it applies to you:

    10 highest (This is NOT a problem in my life. I'm doing really well with this.)
    5 mid (This is SOMEWHAT of a problem in my life.)

    1 lowest (This is a BIG problem in my life. I’m not doing well with this.)

    Motivation

    Happy at Work

    Feeling Lonely

    Healthy Body Weight

    Happy at Home

    Self Esteem

    Exercise 3x/week

    Happy with Friends

    Conflicts with others

    Body Pain

    Meditating Daily

    Depression/Sadness

    Stress/Anxiety

    Getting a job

    Communication Issues

    Tired/Fatigued

    Advancing at work

    Achieving Goals

    Fearful

    Organizational skills

    Making good Decisions

    Mental Focus

    Supporting others

    Paying Bills

    Confidence

    Time Management

    Keeping Commitments

    Job Skills

    Lacking in Purpose

    Planning my Future

    Job Interview Confidence

    Writing a Resume

    Researching Career Options

    How long have you had these challenging issues?

    When the issue is at its worst, how does it feel?

    Does this cause:

    MoodinessSleep InterruptionsRestrictions on Daily Activities/Hobbies

    Does this affect your:

    AttitudeProductivityStaminaPatienceFamily

    Have you ever had a life coach?

    YesNo,

    or a therapist?YesNo   

    If so, when?

    How many sessions?

    If we could find the cause of the problems would you want to get rid of them?YesNo