Give yourself some quiet time to take a breath and be still. Then thoughtfully answer the questions below.
When you have completed the form, click submit. You will see a confirmation page. On that page, click "Edit Your Response", then copy the URL in your browser's search bar to save in a safe place. This URL is your personal link to your survey answers. You will want to review your survey at the end of the course. (You will also be given the option to link to another blank version of the survey on that confirmation page.) Enjoy!
Sign in to Google to save your progress. Learn more
1. *
On a scale of 1 to 10, how would you rate the quality of your life?
extremely unsatisfying
extremely satisfying
2. *
How much quality time do you spend with yourself?
3. *
On a scale of 1 to 10, how happy are you?
not at all happy
extremely happy
4. *
On a scale of 1 to 10, how mindful are you?
not at all mindful
extremely mindful
5. *
On a scale of 1 to 10, how loving are you?
not at all loving
extremely loving
6. *
On a scale of 1 to 10, do you have will-power?
not at all
yes, extremely strong
7. *
What activities do you do during your time off?
8. *
Do you laugh often?
9. *
What is your passion?
10. *
What do you love most?
11. *
What do you live for?
12. *
On a scale of 1 to 10, how strong of a connection do you feel with the following: Spirituality                  
none
extremely strong
*
Passion
none
extremely strong
*
Purpose
none
extremely strong
*
Gratitude
none
extremely strong
*
Sacred Emotions
none
extremely strong
*
Possibility
none
extremely strong
*
Compassion
none
extremely strong
*
Peace
none
extremely strong
*
Meaning
none
extremely strong
*
Empowerment
none
extremely strong
*
Creativity
none
extremely strong
*
Hope
none
extremely strong
*
Joy
none
extremely strong
*
Balance
none
extremely strong
*
Love
none
extremely strong
*
Kindness
none
extremely strong
*
Optimism
none
extremely strong
*
Patience
none
extremely strong
*
Faith
none
extremely strong
*
Bliss
none
extremely strong
13. *
On a scale of 1 to 10, how often do you experience the following: Depression
never
always
*
Anger
never
always
*
Impatience
never
always
*
Stress
never
always
*
Hopelessness
never
always
*
Confusion
never
always
*
Pain
never
always
*
Worry
never
always
*
Sickness
never
always
*
Tiredness
never
always
*
Overwhelm
never
always
*
Exhaustion
never
always
*
Loneliness
never
always
*
Sadness
never
always
*
Distraction
never
always
*
Lethargy
never
always
14. *
Do you often feel as if you have too much on your plate?
15. *
Do you feel as though you are constantly running from task to task?
16. *
Do you often feel as though there are not enough hours in the day to accomplish all you need to accomplish?
17. *
Do you take “time outs” just for yourself during the day?
18. *
Do you struggle to calm down before you go to sleep at night?
19. *
 Do you drink water?  How much?  How Often?
20. *
On a scale of 1 to 10, how often do you eat "on the run" or mindlessly?
never
always
21. *
Do you often prepare food for others?
*
How does the experience of preparing food feel to you?
22. *
Do you have a nightly self-nurturing routine?
23. *
On a scale of 1 to 10, how attractive do you feel?
not at all attractive
extremely attractive
24. *
Do you feel anxious or worried about your health?
*
What concerns you most?
25. *
Do you complain more than you express gratitude?
26. *
Do you feel you constantly put yourself and your priorities last?
27. *
Do you have what you would call healthy, whole relationships?
28. *
Do you feel you can communicate well with people?
With loved ones?
Clear selection
29. *
What or who upsets/angers you the most?
30. *
Do you pray or meditate?
31. *
If you don't pray or meditate, what do you do to “connect"?
32. *
Do you tend to pray for specific things rather than in appreciation?
33. *
Have you started and stopped a meditation practice?
34. *
If you have started and stopped a meditation practice, what are the reasons that you discontinued meditating?
35. *
What questions have you sought guidance for or answers to during meditation or moments of prayer or quiet?
36. *
What answers to these questions would you most fear?
37. *
Would you say you have a refined attunement with a clear, loving and luminous presence of Being? In other words, do you feel a conscious connection with the Sacred, whether in the form of God, Allah, Buddha, Nature, Spirit, Ultimate Reality, Soul, Atman or the Universe?
38. *
What do you draw on for spiritual strength?
39. *
What spiritual truths are you aware of that you do not live by?
40. *
Are you afraid of a closer spiritual connection to the Divine because of the changes it might trigger in your life?
*
If yes, what changes do you think you might have to make?
41. *
Do you pause to feel gratitude, reflect and/or pray before meals?
42. *
Do you know what it is like to feel physically hungry?
43. *
Do you experience frequent food cravings?
*
If yes, for what? Explain how that feels to you.
44. *
Are you an emotional eater? In other words, do you eat when you are not hungry but stressed, confused, sad, bored, lonely, tired or feeling otherwise unfulfilled?
*
If yes, do you see any patterns in this? Explain.
45. *
Do you know what it is like to feel emotionally or spiritually hungry?
*
If yes, describe how that feels to you.
46. *
On a scale of 1-10, how do you rate your relationship with food? (Look at this as you would any other relationship, such as with a friend or family member.)
entirely dysfunctional (only fear and pain)
entirely functional (only joy and love)
47. *
Have you ever enjoyed a healthy relationship with food?
*
Please explain:
48. *
If you were to eat an ideal meal, what would it be? Describe how that would look and feel to you.
49. *
What is stopping you from eating your ideal type of meal now, each and every day?
50. *
Have you ever had an especially exceptional experience of eating?
*
If no, do you believe enjoying an experience like this is possible for you? Why?
51. *
Are you ready to eat mindfully now?  Or, if you don't know what that means, are you ready to learn how to eat mindfully now?
52. *
On a scale of 1 to 10, how difficult is it for you to be honest?
not at all difficult
extremely difficult
*
Please explain:
53. *
Do you think you can be radically honest?
*
What makes you think that?
54. *
Are you ready to take full responsibility for your present experience in life?
*
For the joy?
*
For the pain?
55. *
Do you feel ready to change the experiences in your life that you do not like?
56. *
On a scale of 1 to 10, how motivated are you to change?
not at all motivated
extremely motivated
57. *
Are you ready to keep the promises you make with yourself?
I, ____________________________, promise to the best of my ability, to keep all promises I make to myself while working with Maureen and otherwise, which are made with the intention of aligning myself with Health and Wellness, Wholeness and Truth, with the ultimate purpose of Self Realization, Self Empowerment and Free Creative Expression.                                         In Joy and Love, I am,                                                     *
   Signature ____________________________
MM
/
DD
/
YYYY
IMPORTANT: PLEASE CONTINUE TO THE NEXT PAGE TO COMPLETE THE OPTIONAL, BUT HIGHLY RECOMMENDED, QUESTIONS SECTION.
THE SURVEY IS NOT COMPLETE UNTIL YOU SUBMIT THIS FORM ON PAGE 3
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy