Clergy Wellness Coaching

Stress & Wellness Self Assessment Survey

for those participating in a free Discovery Coaching Session
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.
How stressed out do you generally feel?

(1=very little; 10=highly stressed)?
Check off any of the following stressors you are currently experiencing:

Recently married Recently divorced or separated Estranged from family member Recently moved New job Unhappy with job Attending college Unemployed New baby, adopted child, foster child Loss of loved one Financial upset Caring for elderly parent/s Caring for child/children with special needs Approaching "empty nest" status Approaching/new to retirement Child/children in college Infertility Recent illness or diagnosis of medical condition
Comments
Which of the following do you do to manage stress?

Meditation Visualization Music Adequate rest Yoga Qi Gong Journaling Breath work Exercise Chanting Time with supportive family, friends, mentor, therapist, coach Prayer Meridian "tapping" Nothing
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?

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

1 is Rarely, 10 is Often

Do you eat according to a specific food plan (i.e. Paleo, Vegan, Weight Watchers, your own design, etc.). If so, please explain in the comments.
How is your digestion?

1=Poor; 10 = Great)
Please feel free to explain weight concerns, if any:
How many times a week do you typically exercise?
If you exercise, what do you like to do and where do you do it?
How do you feel about your overall health? List any concerns, if you want to share:
Where would you most like to have a transformational breakthrough in your life / with your health? *
Name *

First Name Last Name
Email *
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Phone Number *

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Date

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Stress & Wellness Self Assessment Survey