Life Domain Satisfaction Survey |

James Fitzgerald Therapy, PLLC

James Fitzgerald, MS, NCC, AAP

1233 Shelburne Rd. Suite 190

South Burlington, VT 05403

Life Domain Satisfaction Survey

This survey will tell us how satisfied you are within each domain of your life, and provide a starting to point to begin our work from. You will also be given room to explore the goals of therapy.

Name *

First

Last

Email *

How satisfied are you in the following domains of health and wellness *

	Very Unsatisfied	Unsatisfied	Neutral	Satisfied	Very Satisfied
Physical	Very UnsatisfiedPhysical Very Unsatisfied	UnsatisfiedPhysical Unsatisfied	NeutralPhysical Neutral	SatisfiedPhysical Satisfied	Very SatisfiedPhysical Very Satisfied
Nutritional	Very UnsatisfiedNutritional Very Unsatisfied	UnsatisfiedNutritional Unsatisfied	NeutralNutritional Neutral	SatisfiedNutritional Satisfied	Very SatisfiedNutritional Very Satisfied
Intellectual	Very UnsatisfiedIntellectual Very Unsatisfied	UnsatisfiedIntellectual Unsatisfied	NeutralIntellectual Neutral	SatisfiedIntellectual Satisfied	Very SatisfiedIntellectual Very Satisfied
Emotional	Very UnsatisfiedEmotional Very Unsatisfied	UnsatisfiedEmotional Unsatisfied	NeutralEmotional Neutral	SatisfiedEmotional Satisfied	Very SatisfiedEmotional Very Satisfied
Psychological	Very UnsatisfiedPsychological Very Unsatisfied	UnsatisfiedPsychological Unsatisfied	NeutralPsychological Neutral	SatisfiedPsychological Satisfied	Very SatisfiedPsychological Very Satisfied
Spiritual/Religious	Very UnsatisfiedSpiritual/Religious Very Unsatisfied	UnsatisfiedSpiritual/Religious Unsatisfied	NeutralSpiritual/Religious Neutral	SatisfiedSpiritual/Religious Satisfied	Very SatisfiedSpiritual/Religious Very Satisfied
Sexual	Very UnsatisfiedSexual Very Unsatisfied	UnsatisfiedSexual Unsatisfied	NeutralSexual Neutral	SatisfiedSexual Satisfied	Very SatisfiedSexual Very Satisfied
Gender	Very UnsatisfiedGender Very Unsatisfied	UnsatisfiedGender Unsatisfied	NeutralGender Neutral	SatisfiedGender Satisfied	Very SatisfiedGender Very Satisfied
Interpersonal Relationships	Very UnsatisfiedInterpersonal Relationships Very Unsatisfied	UnsatisfiedInterpersonal Relationships Unsatisfied	NeutralInterpersonal Relationships Neutral	SatisfiedInterpersonal Relationships Satisfied	Very SatisfiedInterpersonal Relationships Very Satisfied
Social	Very UnsatisfiedSocial Very Unsatisfied	UnsatisfiedSocial Unsatisfied	NeutralSocial Neutral	SatisfiedSocial Satisfied	Very SatisfiedSocial Very Satisfied
Cultural	Very UnsatisfiedCultural Very Unsatisfied	UnsatisfiedCultural Unsatisfied	NeutralCultural Neutral	SatisfiedCultural Satisfied	Very SatisfiedCultural Very Satisfied
Educational	Very UnsatisfiedEducational Very Unsatisfied	UnsatisfiedEducational Unsatisfied	NeutralEducational Neutral	SatisfiedEducational Satisfied	Very SatisfiedEducational Very Satisfied
Occupational	Very UnsatisfiedOccupational Very Unsatisfied	UnsatisfiedOccupational Unsatisfied	NeutralOccupational Neutral	SatisfiedOccupational Satisfied	Very SatisfiedOccupational Very Satisfied
Financial	Very UnsatisfiedFinancial Very Unsatisfied	UnsatisfiedFinancial Unsatisfied	NeutralFinancial Neutral	SatisfiedFinancial Satisfied	Very SatisfiedFinancial Very Satisfied
Environmental	Very UnsatisfiedEnvironmental Very Unsatisfied	UnsatisfiedEnvironmental Unsatisfied	NeutralEnvironmental Neutral	SatisfiedEnvironmental Satisfied	Very SatisfiedEnvironmental Very Satisfied

How motivated are you to start one of the following? *

	Not motivated	Somewhat motivated	Motivated	Highly motivated
Physical Fitness Program	Not motivatedPhysical Fitness Program Not motivated	Somewhat motivatedPhysical Fitness Program Somewhat motivated	MotivatedPhysical Fitness Program Motivated	Highly motivatedPhysical Fitness Program Highly motivated
Nutritional Guidance Plan	Not motivatedNutritional Guidance Plan Not motivated	Somewhat motivatedNutritional Guidance Plan Somewhat motivated	MotivatedNutritional Guidance Plan Motivated	Highly motivatedNutritional Guidance Plan Highly motivated
Formal Mindfulness & Meditation Practice	Not motivatedFormal Mindfulness & Meditation Practice Not motivated	Somewhat motivatedFormal Mindfulness & Meditation Practice Somewhat motivated	MotivatedFormal Mindfulness & Meditation Practice Motivated	Highly motivatedFormal Mindfulness & Meditation Practice Highly motivated
Health & Wellness Education	Not motivatedHealth & Wellness Education Not motivated	Somewhat motivatedHealth & Wellness Education Somewhat motivated	MotivatedHealth & Wellness Education Motivated	Highly motivatedHealth & Wellness Education Highly motivated
Therapy with a professional	Not motivatedTherapy with a professional Not motivated	Somewhat motivatedTherapy with a professional Somewhat motivated	MotivatedTherapy with a professional Motivated	Highly motivatedTherapy with a professional Highly motivated
Couple's Therapy with a Marriage & Family Therapist	Not motivatedCouple's Therapy with a Marriage & Family Therapist Not motivated	Somewhat motivatedCouple's Therapy with a Marriage & Family Therapist Somewhat motivated	MotivatedCouple's Therapy with a Marriage & Family Therapist Motivated	Highly motivatedCouple's Therapy with a Marriage & Family Therapist Highly motivated
Strengthening Your Conscious Self	Not motivatedStrengthening Your Conscious Self Not motivated	Somewhat motivatedStrengthening Your Conscious Self Somewhat motivated	MotivatedStrengthening Your Conscious Self Motivated	Highly motivatedStrengthening Your Conscious Self Highly motivated
Other Workshops, Seminars & Retreats	Not motivatedOther Workshops, Seminars & Retreats Not motivated	Somewhat motivatedOther Workshops, Seminars & Retreats Somewhat motivated	MotivatedOther Workshops, Seminars & Retreats Motivated	Highly motivatedOther Workshops, Seminars & Retreats Highly motivated

Strengthening Your Conscious Self is a copyright protected Health & Wellness program which can address all of the domains of a person's life.

Please use this space to describe your goals of therapy

What do you want to accomplish?

Save and Resume Later