Gratitude To Bliss Wellness Questionnaire Survey

1.Please fill in your first and last name + email address (VERY IMPORTANT so I can respond to your answers!)(Required.)

2.What is the main challenge you are facing right now? This can be physical, mental, or emotional. It can be health related or stress related or something else. All answers will be kept in the strictest confidence.(Required.)

3.Please check which symptoms may be affecting you (your answers will be kept confidential). Check all that apply.(Required.)

Fatigue

Scattered thinking

Anxiety and/or low mood

Other (please specify)

4.How are your symptoms impacting you?(Required.)

5.What are you wanting to create right now in your life?(Required.)

6.How would it impact your life to have that?(Required.)

7.What is one thing you know you need to do to improve your health?(Required.)

8.What is getting in your way from doing this?(Required.)

9.Are you interested in deeper support?(Required.)

Yes

10.Thank you for filling out this questionnaire. I always love connecting with you and learning what your challenges, struggles, hopes, and dreams are so I can better support you. Please let me know if this process was helpful for you. -Lorraine Miller(Required.)

Yes

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