Self-care Assessment Form

Congratulations on your Self-care journey and thank you for entrusting YourStrength to support you along your way. Please take some time to read and answer these 10 questions below that will ensure that the Self/Care/Mindfulness box you receive meets your needs in supporting you along your wonderful Self-care journey.

Name *

First

Last

Shipment Address (# Street, City, Zip, Country)

Email *

Phone

Age

On average, how any hours of sleep do I get each night?

My perfect day consists of?

When I am upset…..

I feel relaxed when....

When I am asked to do something I don’t want to do I...

I enjoy spending time with...

I often feel...

If I have a deadline to meet tomorrow, I....

If someone criticizes me,

Presently in my life I feel

This Self-care Box is for.....

Comment or Message

95020

Note: This assessment will be used only for the purpose of YourStrength LLC creating your Self Care/ Mindfulness box, and will be kept confidential.