Midlife: The Heart of Your Story
1.
Name (First and Last):
2.
email address:
3.
Age:
4.
Role/Position
5.
What are your current challenges with midlife? (Choose all that apply)
Physical Symptoms (elevated heart rate, high blood pressure, chronic pain, reduced immune responses, other)
Emotional: (anxiety, hostility, panic attacks, numbness)
Relationship challenges/failures
Career challenges/failures
How did I get here? I feel like I'm on the wrong path
The things I've always done aren't working anymore
Am I only defined by my accomplishments? What if I don't feel like I've accomplished very much?
It feels like the dreams I had for my life are no longer possible
I wish I had a purpose or a passion
I feel so empty, no matter how hard I work or how much I care for my family
What now?
Other (please specify)
6.
Please share additional specifics on your challenges.
7.
With whom are you currently working (select all that apply):
A counselor or therapist
A coach
A spiritual director
A reflective supervisor
Other (please specify)
8.
Please rank your interest in and availability for the following offerings for participating in "Midlife: The Heart of my Story:"
A 3-hour workshop over Zoom
An in person summer retreat in a beautiful, restorative setting
A seasonal retreat series over the course of a year; some in person, some online
Group spiritual direction via Zoom over a 9-month period
9.
What outcomes would you want or hope for from "Midlife: The Heart of My Story?"