Questionnaire ~ Before Meeting Niika Bless Yourself with Balance - #1 Dear One, I created this survey to jump-start our first conversation together. Please share with me what is important to you, where you feel you stand now in relation to the health, happiness and positive engagement with the world that are your birthright. All of your answers are held confidentially. I look forward to our first meeting together. With respect and love, Niika Step 1 of 3 33% Name* First Last Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Please rate your level of contentment over the last 3 months.*5 - I am happy, focused, peaceful and fulfilled.4 - I am mostly happy, but also angry, worried or sad about something in particular and that's holding me back.3 - My happiness and discomfort seem to equal each other. I'm OK, I guess, but can't life be more fun and productive that this?2 - I'm trying to feel better, but mainly feel sad, angry or distracted most of the time. I do have hope, but I'm not sure about how to improve how I feel and function.1 - I am so unhappy that I am really not functioning in day-to-day life. Hopelessness is an all-too-familiar experience these days.Please indicate your level of contentment over your life so far.*7 - I am usually happy, energetic, focused, peaceful and fulfilled.6 - I am mostly happy, but tend toward anger and resentment.5 - I am mostly happy, but tend toward fearfulness and overwhelm.4 - I am mostly happy, but I lose motivation more than I'd like and tend toward laziness and mild depression.3 - I am nearly always restless, and even when "life is good," my mind tends to focus on the negative.2 - I'm only happy when everything and everyone (including myself) is perfect.1 - I focus more on survival than on happiness. Happiness is for others!Have you suffered any loss, shock or struggle you feel is affecting you now? Can you share a bit about this?How long ago did this begin?Have you experienced any healing moments related to what you have described above? Can you share a bit about this?Are you currently seeing a counselor, psychologist or psychiatrist?* Yes No Do you use alcohol or drugs of any kind to relax?* Yes - at least daily Yes - less than once a week No - rarely or never Do you drink caffeine to gain energy?* Yes - more than twice a day Yes - at least daily No - less than once a week or never Do you meditate?* Yes - Daily, regularly Yes - irregularly, unpredictably Sometimes - only in a group situation No - I have no interest or ability. Do you spend time in Nature?* Yes - Daily, regularly Yes - irregularly, unpredictably Sometimes - only in a group situation No - I have no interest or ability. Do you exercise?* Yes - At least 4 times weekly, regularly Yes - irregularly, unpredictably Sometimes - only in a group situation No - I have no interest or ability Do you prepare food for yourself and/or others?* Yes - Daily, regularly Yes - Irregularly, unpredictably Sometimes - Only when I must. No - I have no interest or opportunity. Do you enjoy social time with others (to play music, sew, play games, etc.)?* Yes - Daily, regularly Yes - Irregularly, unpredictably Sometimes - Only when I must. No - I have no interest or opportunity. Do you have a sense of what your purpose or dharma is at this time in your life? If yes, please tell me more.*If you could see yourself in full health, energy and contentment, how would that feel? How might that look to an outside observer?If health, money, energy and logistics presented no limitation, what would you do with the next 6 months of your life?Do you feel you are in relationship to a higher power? Can you share more with me about your belief, philosophy or religion?Is there one thing you want to do differently in your life, something that keeps coming up for you?