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Name
Surname
Email
Telephone
What is your age:
Select your age
18 - 30
31 - 40
41 - 60
What is your gender:
Select your gender
Man
Woman
How would you rate your overall daily energy level:
Select your overall daily energy level
Very low
Low
Moderate
High
Very high
How would you rate your overall daily serenity level:
Select your overall daily serenity level
Very low
Low
Moderate
High
Very high
What would you say are your 3 most important wishes from the following list:
Increase energy
Find balance
Eliminate stress
Learn to focus
Improve effectiveness
Be healthier
Manage challenges
Surpass limits
Perform better
Reshape the body
Control fears
Let something go
Fix a problem
Relax more
Become serene
Do you currently engage in some form of physical activity:
Select your physical activity frequency
In the past but not currently
Never
Rarely
Moderately
Regularly
Intensively
Do you currently engage in some form of mindfulness practice:
Select your mindfulness practice frequency
In the past but not currently
Never
Rarely
Moderately
Regularly
Intensively
Are you prepared to embrace a profound change:
How much do you feel prepared
No
Unlikely
Maybe
Probably
Certainly
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