About this template
A self-reflection survey serves as a powerful personal assessment tool, helping individuals evaluate their strengths, identify areas for growth, and align daily actions with long-term goals. Whether used for personal development, life planning, or coaching sessions, this template provides a structured way to pause, evaluate current life seasons, and analyze personal priorities.
With Doc2Form, you can instantly turn this layout into a ready-to-use Google Form. It captures insights into self-care habits, relationship values, and top priorities, giving respondents a clear framework for self-discovery. Counselors, educators, and wellness coaches use this assessment to guide constructive conversations, while individuals use it independently to track personal milestones and emotional well-being.
Key features
- Instant conversion into a fully functional Google Form
- Designed for personal development and life planning
- Covers core life areas including priorities and self-care
- Fully customizable questions to match individual or coaching needs
- Collect responses securely and review progress over time
Use cases
- Quarterly personal growth and life milestone reviews
- Client intake for life coaches and wellness counselors
- Student self-assessment exercises in educational settings
- Guided reflection activities during wellness retreats
What this form collects
- Full Name (Short answer)Enter your name or leave blank if you prefer to keep this reflection anonymous.
- Current Life Season (Short answer)Describe the current chapter of your life in a few words (e.g., transition, busy, rebuilding, resting).
- Top Priorities (Paragraph)What are your top three priorities right now? Consider career, relationships, health, and personal growth.
- Self-Love Status (Linear scale)Rate how well you currently practice self-compassion and patience with yourself.
- Self-Care Status (Linear scale)How satisfied are you with your current physical and mental self-care routine?
- Worry About Uncontrollable Matters (Multiple choice)How often do you find yourself spending energy on things outside of your control?
- Unforgiveness Status (Paragraph)Are there past grievances or lingering resentments you feel are holding you back?
- Definition of Love (Paragraph)In your own words, how do you define genuine love and support in relationships?
- Relationship Values & Contribution (Paragraph)What do you value most in your close relationships, and what do you feel is your greatest contribution to them?
- Self-Worth Belief (Multiple choice)Do you fundamentally believe that you are worthy of love, success, and good things?
- Ten Words Self-Description (Short answer)Describe yourself in exactly ten words or fewer.
- Feelings About Your Self-Description (Paragraph)How do you feel about the description you just provided? Does it bring you pride, dissatisfaction, or surprise?
FAQ
How do I use this self-reflection template with Doc2Form?
Simply use Doc2Form to instantly convert this template into a Google Form, allowing you to customize questions and share the link with respondents in seconds.
Can I edit the questions after generating the form?
Yes. Once the form is created in your Google account, you have full control to add, remove, or modify any questions.
Are the responses kept private?
All responses go directly to your personal Google Form results sheet, ensuring complete privacy and security under your Google account settings.
Who is this survey template best for?
It is ideal for individuals pursuing personal growth, life coaches, counselors, and educators helping students build self-awareness.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.