Untitled Survey

Initial Questionaire

Please complete this short survey before beginning the EmotionMind Dynamic Programme.

Please enter your name

First Name

Last Name

Please enter your email address

Email

You are asked to rate the following sections, with scores that show how much you agree or disagreee with that statement. The scores will be from 1 to 5, where 1 is strongly disagree and 5 is strongly agree.

I feel happy, fulfilled and satisfied with my life

1 2 3 4 5

I am fit, healthy and feel well

1 2 3 4 5

I sleep well and wake feeling energised

1 2 3 4 5

I have healthy relationships with others

1 2 3 4 5

I like the person that I am, and feel confident

1 2 3 4 5

I am the parent that I want to be

1 2 3 4 5

I am close to my friends

1 2 3 4 5

I enjoy my job and feel satisfied in my career

1 2 3 4 5

I do things that make me smile and laugh

1 2 3 4 5

I am coping well in life

1 2 3 4 5

I am motivated and productive

1 2 3 4 5

How do your responses to these statements affect your life now?

How long has your life felt this way?

If nothing were to change, what will life look like for you in 5 years?

If there was a solution that could change your life, what would that mean to you?