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Questionnaire
Chaya
2024-10-06T18:55:17+02:00
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GENERAL INFO
1. GENERAL INFO: Name
*
First
Last
Country and State of residence?
*
Age
*
Marital status, Children (ages, if any).
*
This will help me understand your close environment.
2. QUESTIONS ABOUT YOUR ANXIETY: How long have you been suffering from anxiety?
*
What type(s) of anxiety are you suffering from (social, generalized etc)? Please let me know if you have been diagnosed with anxiety or if it's a self report (both are ok for me).
If you don't know, you can leave this empty.
On a scale from 1 to 10, how strong is your anxiety lately?
*
Tell me about how anxiety is impacting your life (daily life, relations, work, achieving projects and dreams...). What consequences of this excessive anxiety do you see in your life?
*
Do you know how your anxiety gets triggered? Please share some examples.
*
What have you already done and maybe still doing to try to decrease your anxiety (ex: practices, therapy, meds, diet changes, supplements etc)? Please comment about any successful or unsuccessful experiences.
*
Anxiety is often being associated with other things... Please let me know if you have (or suspect to have) any mental and/or personality disorder (autism, ADHD, depression, OCD...).
*
At the moment, do you take any medications and/or supplements? If yes, please list them below.
*
Are you currently seeing a therapist/psychologist/psychiatrist right now? If so, please share your reason(s)?
*
Anxiety can have roots in our body's condition. Do you have any physical disease or chronic symptoms? How are your periods (regular or not, heavy or light...)? Do you know if your hormones are balanced?
*
3. ABOUT LIFECALMA COACHING: Could you commit mentally, emotionally and financially for an intense coaching program, for at least 3 months? -After these first 3 months, the coaching can be lighter-
*
Yes
Not sure
Describe your main motivation and goal(s) for this Coaching.
*
Psychology
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Please select your level of interest for this field of LifeCalma's Coaching
Breathing
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Please select your level of interest for this field of LifeCalma's Coaching
Spirituality
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Please select your level of interest for this field of LifeCalma's Coaching
Naturopathy (natural practices and art, music-therapy)
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Please select your level of interest for this field of LifeCalma's Coaching
Body Moves
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Please select your level of interest for this field of LifeCalma's Coaching
Nutrition & Supplements
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Please select your level of interest for this field of LifeCalma's Coaching
Do you have any questions about one or more of these six categories in LifeCalma's Coaching? (optional)
Do you think you have already a good knowledge and experiences in one or more fields? LifeCalma's 6 fields: Psychology, Breathing, Spirituality, Naturopathy, BodyMoves, Nutrition. Please elaborate (optional).
*
Nutrition is an essential part of how our nervous system and brain work. At the moment, do you follow a particular diet? If so, please name it or describe it.
*
I will suggest you various exercises and ideas to improve your anxiety, in each of the 6 categories. Most are free, though some have a cost. For best results, it's important to have the capacity to invest in for example: supplements, various health tests... Is your budget narrow, or would it allow for extra costs? Please elaborate.
*
4. YOUR PERSONALITY and IMAGINATION: How would you describe your personality as a child (before 8 years old)? -in some words or few sentences-
*
How would you describe your personality now? -in some words or few sentences-
*
Have you observed your senses being more developed than average, or easier to feel over stimulated (audition, visual...)?
*
Do you consider yourself:
*
overly organized
very well organized
organized enough
organized and disorganized (depending subjects, moments...)
disorganized but manageable
chaotic and it's a struggle
Do you often procrastinate on important things? If so, please share one or two examples.
*
Do you consider yourself a perfectionist? If so, please share one or two examples.
*
If you could talk to your anxiety... What would you tell her right now?!
*
If i gave you a tennis ball right now. Besides playing tennis, what else would you do with it? Be creative and descriptive! Up to 5 ideas of other uses for the tennis ball are welcome.
*
health to Moves
5. CLOSURE: Use this space to add anything else you consider relevant for me to know (optional).
Thank you for your time and energy!
You will get a message shortly after i receive your answers.
Send
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
GENERAL INFO
1. GENERAL INFO: Name
*
First
Last
Country and State of residence?
*
Age
*
Marital status, Children (ages, if any).
*
This will help me understand your close environment.
2. QUESTIONS ABOUT YOUR ANXIETY: How long have you been suffering from anxiety?
*
What type(s) of anxiety are you suffering from (social, generalized etc)? Please let me know if you have been diagnosed with anxiety or if it's a self report (both are ok for me).
If you don’t know, you can leave this empty.
On a scale from 1 to 10, how strong is your anxiety lately?
*
Tell me about how anxiety is impacting your life (daily life, relations, work, achieving projects and dreams…). What consequences of this excessive anxiety do you see in your life?
*
Do you know how your anxiety gets triggered? Please share some examples.
*
What have you already done and maybe still doing to try to decrease your anxiety (ex: practices, therapy, meds, diet changes, supplements etc)? Please comment about any successful or unsuccessful experiences.
*
Anxiety is often being associated with other things… Please let me know if you have (or suspect to have) any mental and/or personality disorder (autism, ADHD, depression, OCD…).
*
At the moment, do you take any medications and/or supplements? If yes, please list them below.
*
Are you currently seeing a therapist/psychologist/psychiatrist right now? If so, please share your reason(s)?
*
Anxiety can have roots in our body's condition. Do you have any physical disease or chronic symptoms? How are your periods (regular or not, heavy or light…)? Do you know if your hormones are balanced?
*
3. ABOUT LIFECALMA COACHING: Could you commit mentally, emotionally and financially for an intense coaching program, for at least 3 months? -After these first 3 months, the coaching can be lighter-
*
Yes
Not sure
Describe your main motivation and goal(s) for this Coaching.
*
Psychology
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Please select your level of interest for this field of LifeCalma’s Coaching
Breathing
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Please select your level of interest for this field of LifeCalma’s Coaching
Spirituality
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Please select your level of interest for this field of LifeCalma’s Coaching
Naturopathy (natural practices and art, music-therapy)
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Please select your level of interest for this field of LifeCalma’s Coaching
Body Moves
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Please select your level of interest for this field of LifeCalma’s Coaching
Nutrition & Supplements
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Please select your level of interest for this field of LifeCalma’s Coaching
Do you have any questions about one or more of these six categories in LifeCalma's Coaching? (optional)
Do you think you have already a good knowledge and experiences in one or more fields? LifeCalma's 6 fields: Psychology, Breathing, Spirituality, Naturopathy, BodyMoves, Nutrition. Please elaborate (optional).
*
Nutrition is an essential part of how our nervous system and brain work. At the moment, do you follow a particular diet? If so, please name it or describe it.
*
I will suggest you various exercises and ideas to improve your anxiety, in each of the 6 categories. Most are free, though some have a cost. For best results, it's important to have the capacity to invest in for example: supplements, various health tests… Is your budget narrow, or would it allow for extra costs? Please elaborate.
*
4. YOUR PERSONALITY and IMAGINATION: How would you describe your personality as a child (before 8 years old)? -in some words or few sentences-
*
How would you describe your personality now? -in some words or few sentences-
*
Have you observed your senses being more developed than average, or easier to feel over stimulated (audition, visual…)?
*
Do you consider yourself:
*
overly organized
very well organized
organized enough
organized and disorganized (depending subjects, moments…)
disorganized but manageable
chaotic and it’s a struggle
Do you often procrastinate on important things? If so, please share one or two examples.
*
Do you consider yourself a perfectionist? If so, please share one or two examples.
*
If you could talk to your anxiety… What would you tell her right now?!
*
personality about me
If i gave you a tennis ball right now. Besides playing tennis, what else would you do with it? Be creative and descriptive! Up to 5 ideas of other uses for the tennis ball are welcome.
*
5. CLOSURE: Use this space to add anything else you consider relevant for me to know (optional).
Thank you for your time and energy!
You will get a message shortly after i receive your answers.
Send
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