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Well-being, Culture, and Worldview
Please feel free to fill out this form as you see fit, you are not required to answer every question, it has just been made to give us a idea of how to work with you effectively.
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Name
*
Your answer
What’s your energy level in your life at the moment?
Low
1
2
3
4
5
High
Clear selection
Are you being treated for any medical conditions or diseases?
Your answer
Do you sleep well?
Badly
1
2
3
4
5
Soundly
Clear selection
What are your greatest energy sources and energy robbers in everyday life?
Your answer
How do you refuel your energy?
Your answer
My work/life balance is (good/bad/needs improvement) because....
Your answer
What protects you from burning out?
Your answer
Do you have people in your life who are reliant on you for care?
Your answer
Are you reliant on others for care or services?
Your answer
Do you have someone that you can share your problems and worries with?
No
Yes
Other:
One thing I did recently that I was proud of was…
Your answer
My ability to focus on my work is...
Low
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5
High
Clear selection
I can tolerate mistakes with myself and others
Never
Occasionally
Sometimes
Often
Always
Clear selection
What are 3 things I like about myself?
Your answer
I find conflicts helpful / disturbing, because…
Your answer
I trust my own decisions without needing opinions from others
Never
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2
3
4
5
Always
Clear selection
Recognition and appreciation are for me...
Your answer
I believe I have sufficient access to financial and institutional support for my work (mindset)
Your answer
What do I think about myself in relation to my work?
Your answer
What goals motivate me?
Your answer
My cultural background and upbringing was... (eg. I grew up as (not) part of the dominant culture where I lived which was...in x country, where I spoke these languages... the cultural beliefs included... traditions included... values included)
Your answer
The following values from my upbringing still guide me...
Your answer
What specifically are you looking for in a mentorship, and why would you like that from us at OFEN?
Your answer
Any further information you want to share?
Your answer
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