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“G.R.E.E.N.H.O.U.S.E”
(Grounding Retreat to Enliven, Energize, Naturally
Heal
and Overcome Undesired Stress Elements)
QUESTIONNAIRE Are you ever tense? Nervous? Anxious? Completely stressed out?
Do you catch yourself thinking that there is just never enough time?
Are you feeling that the complexity of fast-paced life in a world filled with “time saving” devices is distracting you from what it is that you really want to do?
Here is your chance to finally reveal your innermost secret sources of frustration!
For each question please rank your choices from 1 to 5, with 1 being the most relevant. If a particular item does not apply to you, just leave it blank.
Your responses will be treated with utmost confidentiality.
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| 1. Of the items listed below, which ones are most intrusive to your privacy and to your peace of mind?
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| Computer |
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| Television |
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| Telephone |
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| Cell Phone (yours) |
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| Cell Phone (other people’s) |
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| Blackberry |
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| Email |
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| Web Surfing, Blogs, etc. |
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| Internet Shopping, Ebay, etc. |
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| Junk Mail |
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| Computer Viruses |
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| Video Games |
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| Sports News |
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| Alarm clock |
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| Appliance Noise |
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| Taxes |
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| Paperwork |
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| Deadlines |
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| To Do List |
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| Other
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| Other
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2. Would you consider yourself “addicted” to any one of the above? Which?
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3. Are there any of the above that you wish had never been invented?
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| 4. Which type of news or media delivery is causing the most amounts of stress to you?
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| TV News |
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| "The War" |
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| Email |
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| Snail Mail |
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| Daily paper |
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| Blackberry |
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| Junk Mail |
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| Radio |
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| Evangelists |
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| Gossip magazines |
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| Other
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| Other
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| 5. Are there any people in your life who are draining excessive amounts of your energy? |
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| Abusive Boss |
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| Co-workers |
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| Employees |
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| High Maintenance Partner |
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| Unruly Children |
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| Parents |
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| Mother in Law |
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| Dysfunctional relatives |
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| Teachers |
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| Students |
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| Incompetent Contractors |
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| Telemarketers |
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| Your “Ex” |
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| Needy Friends |
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| Rude Neighbors |
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| Your Neurotic Pet |
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| President Bush |
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| Other
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| Other
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| 6. What do you do in order to escape from the stress from either one or all of the above? |
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| Eating |
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| Watching TV |
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| Naps |
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| Yoga |
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| Meditation |
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| Walking/Running |
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| Time in Nature |
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| Reading |
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| Movies |
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| Travel |
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| Chewing Gum |
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| Sex |
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| Dancing |
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| Cooking |
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| Sports |
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| Knitting |
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| Visits to your Therapist |
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| Massages |
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| Art Making |
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| Time alone |
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| Journaling |
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| Alcohol |
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| Bubble Baths |
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| Other
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| Other
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| 7. After filling out this questionnaire, are you feeling |
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8. Is there anything you would like to add or comment on?
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Thank you for your responses,
AKS |