Clergy Wellness Coaching

Wellness Coaching Survey

for Clergy, Administrators/Staff & Their Family Members
Please feel free to answer as little or as much of this self assessment as you are comfortable with. It will help me understand, in a quick snapshot, the areas of greatest importance to you. Rest assured that your answers will be held in the strictest confidentiality.
Please answer:

1A: if you are CLERGY

1B: if you are a CONGREGATIONAL ADMINISTRATOR / STAFF

1C: if you are the FAMILY MEMBER of a clergy or administrator (partner, spouse, adult child, etc.)
1A. FOR CLERGY: What is your title/position and setting you work in currently (i.e. congregation, outreach, student, chaplaincy, retired)?
1B. FOR CONGREGATIONAL ADMINISTRATORS / STAFF: What is your title/position and setting you work in currently (i.e. congregation, outreach, student, retired)?
1C. FOR FAMILY (OF CLERGY): how do you spend your time (work in or outside of home, volunteer in or outside of congregation, other)?
2. How much joy and fulfillment do you derive from the role identified above?

(1=very little joy; 10=immense joy; )
3. How stressed out do you feel?

(1=very little; 10=highly stressed)?

4. How often do you feel like you have adequate time to eat and not feel rushed?

	1	2	3	4	5	6	7	8	9	10
Rarely											Often

5. How is your digestion?

1=Poor; 10 = Great)
6. How many times a week do you typically exercise?
If you exercise, what do you like to do and where do you do it?
7. Please feel free to explain weight concerns, if any:
8. How do you feel about your overall health? List any concerns, if you want to share:
9. Do you feel like you have time to nourish your own spiritual life?
Comments
10. Which of the following do you do to manage stress?

Prayer Meditation Visualization Music Adequate rest Yoga Qi Gong Journaling Breath work Exercise Chanting Time with supportive family, friends, mentor, therapist, coach Nothing
11. How and when do you feel most overwhelmed?
12. Sabbath / Time Off: Do you have designated time in your schedule for restoration (physically, emotionally, spiritually)? Do you unplug?
13. What would you like to be doing to manage stress/improve the way you feel that you are just not doing because you can't find the time?
14. Is there anything else you'd like to share?
Name

First Name Last Name
Email
example@example.com
Phone Number

- Area Code Phone Number
Date

- Month - Day Year
Date
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Wellness Coaching Survey