Life Changing Break Questionnaire

The purpose of this short questionnaire is to establish how you feel about yourself and your life ~ and to identify specific issues you may like to explore during your break.
If you do not wish to answer a particular question, just leave a blank. Along with all that we do here, your answers will remain entirely confidential.

Your Contact Details

Your Name:	Required
E-mail:	Required

How you feel about life at the moment...

Please rate 0-10, with 10 being perfect		Comment
Relationship with partner
Relationships with family
Relationships at work
Other work-related issues
Your physical health/energy
Your sense of self-worth
Your experience of abundance
Your feeling of spirituality
Your state of happiness
Your sense of belonging
Your particular likes
Your particular dislikes

Current Beliefs...

Currently Feeling...

Objectives

During your Life Changing Break,
what changes would you really like to make to your life?

Additional Information

Please use this space to tell us anything else about yourself that you consider relevant ~ and to ask any questions you may have.

Belvedere is the home of VISION unlimited ~ a fresh outlook for life

	Please specify
My approach to life significantly affects it	Yes Not Sure No
An open mind is a weak mind	Yes Not Sure No
No-one can help me if I don't want them to	Yes Not Sure No
Many of my problems are caused by others	Yes Not Sure No
Others will change as I do	Yes Not Sure No
Life is hard	Yes Not Sure No
I deserve everything that is good	Yes Not Sure No
I am loved	Yes Not Sure No
I am powerless to change my life	Yes Not Sure No

Please select all that apply
Angry	Sad	Guilty	Tired
Stuck	Happy	Contented	Confused
Betrayed	Silly	Numb	Fearful
Lonely	Apprehensive	Exploited	Unloved