1-Minute Burnout Assessment

1-Minute Burnout Assessment

This assessment follows a University tested model and is intended to serve as a quick guide to help you get a feel for where you are at this time from the energy perspective. I invite you to take one minute to answer these questions honestly and authentically. Self-honesty is the first step to bringing change to your life. Once you have completed the assessment, you’ll receive a follow up email with your score, interpretation and suggestions for next steps.
Full Name*

First NameLast Name
Email*
example@email.com

Your Thoughts*

	Never	Rarely	1-2 times a month	1-2 times a week	Daily
How often do you experience running thoughts?
How often do you feel like quitting your job, changing professions, leaving a relationship or walking away from it all?

Your Actions*

	Never	Rarely	1-2 times a month	1-2 times a week	Daily
How often do you drink alcohol or take medication or chemicals to help you relax or dull pain or stress?
How often do you “snap” at others because you feel angry or annoyed?

Your Feelings*

	Never	Rarely	1-2 times a month	1-2 times a week	Daily
How often do you feel attacked by others?
How often do you feel heavy or weighed down by the pressures of life or a relationship?

Your Memory*

	Never	Rarely	1-2 times a month	1-2 times a week	Daily
How often do you have difficulty remembering something simple?
How often do you feel haunted by a disturbing or painful memory?

Your Relationships*

	Never	Rarely	1-2 times a month	1-2 times a week	Daily
How often do you feel drained after interacting with a specific person?
How often do you feel like you are giving more to a relationship than you are receiving?

Your Physical Symptoms*

	Never	Rarely	1-2 times a month	1-2 times a week	Daily
How often do you get headaches?
How often do you experience anxiety or depression?