Teacher & Student Questionnaire

Name *

First Name

Last Name

Phone

(###)

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Understanding Your Role and Awareness

Are you a teacher or a student?

Teacher

Student

How familiar are you with the concepts of mindset coaching and personal development?

Very familiar – I’ve read books or attended similar programs.

Somewhat familiar – I’ve heard of it but never explored it deeply.

Not familiar – This is a new concept to me.

What is your current level or role?

High school student

College/university student

Teacher (K–12)

Teacher (higher education)

Exploring Goals and Aspirations

What is your primary goal for participating this program (or implementing this program into school)?

Learning how to set and achieve meaningful goals

Building confidence and overcoming self-doubt

Developing a success-oriented mindset

Improving communication and leadership skills

What challenges do you currently face in reaching your potential?

Lack of clear goals or direction

Procrastination or difficulty staying focused

Fear of failure or judgment

Overwhelm from workload or responsibilities

Difficulty breaking bad habits

Other

Assessing Readiness and Beliefs

How do you currently approach achieving your goals?

I take consistent action and adjust as needed.

I have good intentions but struggle with follow-through. to change them

I often feel stuck and unsure of where to start.

Which of these beliefs resonates with you the most?

Success is about hard work and persistence.

Success is about having the right mindset and habits.

Success is about luck or circumstances.

Other

9. On a scale of 1–10, how open are you to learning new strategies for success? (Select a number where 1 = Not open and 10 = Fully open)

1

2

3

4

5

6

7

8

9

10

Commitment and Implementation

How much time can you dedicate to this program each week?

Less than 1 hour/week

1–3 hours/week

3–5 hours/week

5+ hours/week

How do you prefer to learn?

Visual (videos, presentations, and diagrams)

Hands-on (practicing new techniques)

Discussion-based (group learning and collaboration)

Independent (reading and self-study)

What support do you feel would help you most during this program? (Select all that apply)

Step-by-step guidance to stay on track

Tools for better time management and focus

Strategies for overcoming fear and self-doubt

Energy healing to help reduce stress and improve clarity

Other