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Happy & Whole Mother's Survey
1. Default Section
When you wake up in the morning how happy do you feel?
When you wake up in the morning how happy do you feel?
Awake Excited To Start My Day
Awake Happy
Awake Nuetral
Awake unhappy
Awake dreadding the day
Do you have a job besides mothering & taking care of your family?
Do you have a job besides mothering & taking care of your family?
No
Yes, I work from home
Yes, I go to the office
If you are a stay at home mother, how happy are you?
If you are a stay at home mother, how happy are you?
VERY! I love being with my children
Most Days Happy
Miss my job and being around adults
Hate it, I'm not cut out for this kind of work
Other
If you are a work at home mother, are you
If you are a work at home mother, are you
An entrepreneur
Work for someone else but at home
Work at home mothers, how happy are you?
Work at home mothers, how happy are you?
VERY! Would not change a thing
It can be challenging, yet I still enjoy it
Not So Much, miss contact with others
Hate it
Other (please specify)
Working Mothers that leave home, how happy are you?
Working Mothers that leave home, how happy are you?
VERY! Would not change a thing
Somedays love it, others not so much
Would love to have more time with family
Hate it
Other (please specify)
What are you currently struggling with?
What are you currently struggling with?
My marriage
My parenting
Balancing family and work
Keeping my house clean
Other (please specify)
I feel I need help with…?
I feel I need help with…?
My relationship with my partner
My children
My Famliy of origin
My extended family
If I were to seek help, I would ask for help from?
If I were to seek help, I would ask for help from?
My doctor
A therapist
A priest
Life coach
Friend
In the past I have received help from...
In the past I have received help from...
A therapist
A priest
A life coach
A doctor
Other (please specify)
The help I received was helpful...
The help I received was helpful...
Yes
No
Other (please specify)
Do you work currently with a therapist or life coach?
Do you work currently with a therapist or life coach?
Yes
No
Other (please specify)
What prevents you from seeking help?
What prevents you from seeking help?
Finances
Time
Fear
Pride
My Partner
Negative previous experiences after asking for help
Other (please specify)
I feel that I am very capable in the following areas
I feel that I am very capable in the following areas
Communicating with my partner
Communicating with my children
Maintaining a household
Mothering
My other job besides mothering
Taking good care of myself in addition to caring for others
Other (please specify)
I feel that I am not very proficient in the following areas
I feel that I am not very proficient in the following areas
Communicating with my partner
Communicating with my children
Maintaining a household
Mothering
My other job besides mothering
Taking good care of myself
Other (please specify)
Would you please share your name and e-mail address, so I may follow up with you. Thanks!
Would you please share your name and e-mail address, so I may follow up with you. Thanks!
Experiences that I have had that might hold me back today are
Experiences that I have had that might hold me back today are
Abuse
Addiction
Learning difficulties
Low self esteem
Other (please specify)
If I could magically change my life I would
If I could magically change my life I would
Be wealthier
Be a better mother
Have more time
Have a better partner
Other (please specify)
Do you want help from someone?
Do you want help from someone?
Yes
No
maybe
I most want help with the following area(s)
I most want help with the following area(s)
My relatioship with partner
My relationship with my children
My relationship with myself
My relationship with my family of origin
Other (please specify)
Do you enjoy playing with your kids?
Do you enjoy playing with your kids?
Yes! Love it
Sometimes
It's hard to balance work/play time
No, it's really challenging for me
Other (please specify)
What was your childhood like?
What was your childhood like?
Wonderful! Could not have asked for anything more
Good, with some challenges
Challenging, lot's of dysfunction
awful
Other (please specify)
If your childhood was challenging, which of these describe your experiences?
If your childhood was challenging, which of these describe your experiences?
Alcoholism
Spanking
Emotional neglect/abuse
Physical abuse
Sexual abuse
Other (please specify)
Do you see negative things from your childhood repeating themselves in your current situations?
Do you see negative things from your childhood repeating themselves in your current situations?
Yes
Sort of
No
Other (please specify)
Which behaviors do you feel challenged by?
Which behaviors do you feel challenged by?
Spanking
Yelling
Anger
Rage
Other (please specify)
Would you like to enjoy your life more?
Would you like to enjoy your life more?
Yes
No, I'm great
Other (please specify)
What is your number 1 parenting challenge?
What is your number 1 parenting challenge?
What is your number one challenge with your partner?
What is your number one challenge with your partner?
Would you like to enJoy parenting more?
Would you like to enJoy parenting more?
Yes
No, I'm having a blast!
Other (please specify)
When you lay your head down on the pillow at night, do you feel...
When you lay your head down on the pillow at night, do you feel...
Happy & Content
Fine
Just plan tired
Thank goodness this day is over
Other (please specify)
How important is improving your relationship with your family to you?
How important is improving your relationship with your family to you?
Very, my relationship with my family is paramount!
Sort of, yet where do I find the time
I'm good, no need for improvement
Other (please specify)
Is there anything else that you would want to share with me so that I can help you when we speak at your complimentary coaching session?
Is there anything else that you would want to share with me so that I can help you when we speak at your complimentary coaching session?
Thanks! Please continue on to the next page and receive your free gift and special report :-)
Thanks! Please continue on to the next page and receive your free gift and special report :-)
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