What Would Help You be Healthy & Happy!
The intention of this survey is to understand the real needs of real women, diverse in age, race, identity, lifestyle, socio-economic levels - towards living a life of their choice as a healthy and happy human being. By listening to you, the practitioners of Labrys Healthcare Circle will be creating Health and Wellness Classes and Programs starting in January 2020.
If you have any question please contact Roke Noir at
Your information is safe with us. We respect your privacy and will not share this with anyone.
Labrys Healthcare Practitioners
Date of Birth (we want to wish you Happy Birthday)
I need help with: (physical, mental, and/or emotional, life challenges that you are struggling with)
Things that get in the way of living a life I love are: (choose all that are relevant and add more at the end)
I feel anxious, worried, stressed, fearful, and overwhelmed.
I feel depressed, hopeless, helpless, incapable of doing things, without purpose or drive, not wanting to get up or get out.
I depend on someone else to keep me engaged and happy. Else I feel lonely, sad, and lost.
I feel small, not good enough, ashamed, useless, or incompetent.
I get angry, judgmental and blaming, and at times violent, too often, too much, and too quickly.
I feel lost and without purpose, have difficulty making up my mind and seek external validation.
I struggle with saying no and setting boundaries. I end up feeling resentful & taken advantage of.
I am afraid of what will happen if I am not in control. I become rigid and inflexible, unempathetic.
I have difficulty knowing what I need and asking for it, as I put other people's needs before my own.
I go into "poor me", feel I am a victim of circumstances, and need others to rescue me.
I have deep set patterns, triggers, stories, and trauma.
I feel resentful and bitter about things that have happened and feel guilt, shame, & blame around them.
It is hard for me to ask for or/and receive help.
I want to: (choose all that are relevant and add more at the end)
Design & Create the Next Phase of my life.
Be in intimate loving relationship(s) without losing myself.
Learn how to define what I want & manifest those dreams.
Know who I am, figure out my purpose, and find my place within everything.
Make more money, doing things I love and care about.
I want to walk my path through life with a sense of confidence and self worth.
Get better at decision making, and make mindful and informed choices in my life.
Eat well, sleep, exercise, meditate, have fun - create and live a healthy life style.
Express myself more through creative outlets like writing, painting, improv, singing, drumming, etc.
Make time for myself to do and be as I like it.
Find community and have better relationships, from a place of choice, to my friends and family.
Value things I do and ask to be paid appropriately.
Keep the right kind of people in your life. And let go of those who are subtractive.
Define & Find/Create the right kind of work for me.
Trust that there is Help available, be able to ask for and receive help.
I want to grow/develop life skills around: (choose all that are relevant and add more at the end)
Self Care & Self Actualization - Make space, time, and choices that would benefit me.
Money & Debt Management
Relationships: Dating, Building, & Maintaining Intimate Loving Relationship(s)
Having a healthy lifestyle - Eating & Sleeping Well, Exercising, Having a spiritual practice, Nurturing engagements etc.
Starting my own Practice or Business
Making & Keeping a Home I love
Conflict Resolution & Mediation - Dealing with the Difficult People in my life
Having a Balanced Life
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