Poetry Therapy Questionnaire
Thank you so much for your interest in Poetry Therapy! I am providing this service during these trying times, to give you some daily inspiration to stay positive. If you'd prefer a prompt and contactless service as opposed to a video session, please fill out the form below. Your answers will give me an idea of your current living and working situation, along with how you may be feeling during this pandemic, without me having to contact you further. If you'd prefer not to answer some of these questions, you may leave them blank. Once I analyze your answers, I will write a custom poem for you within 12-24 hours!
All sessions are donation based as I know we are all going through a tough time financially. If at the end of your session you would like to donate, kindly send donations to @jacklyn-zoppi on Venmo.
Name (first and last)
Instagram and/or Facebook handle
Please leave your preferred contact method (list your phone number or email below)
What city/state do you live in?
What is your living situation?
I live alone
I live with my spouse
I live with a family member (or members)
I have a roommate (or roommates)
What is your occupation?
What is your current work situation?
I am still working. My job is considered essential.
I am able to work from home through my employer.
I am self employed and still in business as usual.
I am self employed, but have lost clients due to the pandemic.
I have been furloughed due to the pandemic.
How have you been feeling lately? Focus on how you've been feeling as time has gone on, and try to depict what the strongest feelings are.
Give me 5 words that sum up your feelings
Have you noticed anything that triggers you to feel certain emotions such as anxiety, depression or fear? (Examples might be watching the news, not being able to see your family members, having to change your wedding date, etc.)
What are some positive thoughts that you’ve noticed will make you feel better when you’re feeling down?
Give me 5 positive words you would like me to focus on, to inspire you and lift your spirits
What are some things that make you feel better in your physical environment? (sunshine, plants, your pets, scented candles etc.)
What are some things you like to do to make yourself feel better? (painting, drawing, baking, reading, watching tv, playing with your dog, going for walks, etc.)
What do you miss the most during this time of change?
What do you hope to get from this poem? What is one thing you want to remind yourself of every day when you wake up in the morning?
Are you interested in any of the following products once you receive your poem?
Digital graphics (includes phone wallpaper and instagram square size) - $15
5x7 Poetry print + digital graphics - $25
8x10 Poetry print + digital graphics = $40
Just the typed poem is great
If you would like a poetry print, please leave your address below.
Send me a copy of my responses.
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