Course Reflection Questionnaire
Answer from where you are today, no judgment, no pressure.
Your Information:
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Self Assessment:
How would you rate your relationship with yourself?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What improvements have you noticed in the last 3 months?
What would make your relationship with yourself a 10?
How would you rate your positive coping skills when things get tough? (In other words, how often do you turn to things like meditation, exercise, and self-care when you’re feeling bad?)
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What improvements have you noticed in the last 3 months?
What would make it a 10?
How would you rate your ability to deal with anger?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What improvements have you noticed in the last 3 months?
What would make it a 10?
How would you rate your relationship to your family of origin?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What improvements have you noticed in the last 3 months?
What would make it a 10?
How would you rate your relationship with food, alcohol, and/or drugs?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What improvements have you noticed in the last 3 months?
What would make it a 10?
How would you rate your career?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What improvements have you noticed in the last 3 months?
What would make it a 10?
How would you rate your relationship with money?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What improvements have you noticed in the last 3 months?
What would make it a 10?
How would you rate the friendships in your life?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What improvements have you noticed in the last 3 months?
What would make it a 10?
How would you rate your romantic life?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What improvements have you noticed in the last 3 months?
What would make it a 10?
How would you rate your ability to communicate effectively?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What improvements have you noticed in the last 3 months?
What would make it a 10?
Course Reflections:
What was the main reason you wanted to participate in this course?
With this reason in mind, what progress did you make during this course?
What lessons and/or practices from this course have you found supportive?
What do you see as your main challenges going forward?
What tools will you use to meet those challenges?
In light of what you learned in this course, what is your next set of intentions?
Would you recommend this course to someone else, if yes, what would you tell them?
Can I use your answer (or an excerpt from) the question above as a testimonial?
Yes
No
Is there anything else you would like me to know?
Submit
Should be Empty: