Personal Peace Assessment

Client Full Name *

Date of Assessment *

Your Email Address *

Used so Dr. Nicole can follow up with you.

Session Number / Notes (optional)

For each category, drag the slider to reflect your current level of peace or satisfaction (0 = none, 100 = complete). Your five scores will be averaged to give your Personal Peace Index.

SpiritualFaith, purpose, inner connection, values alignment

50%

PhysicalHealth, energy, body care, sleep, nutrition

50%

Mental / EmotionalMindset, emotional regulation, mental wellness, clarity

50%

Social / RelationalRelationships, community, support systems, belonging

50%

FinancialFinancial stability, security, stewardship, provision

50%

Personal Peace Index

50%

Average of your five category scores

Reflection — What area needs the most attention right now? (optional)

You’ll be able to download or print your own copy after submitting.

✅ Assessment submitted successfully. Thank you.

Save this copy for your own records. Your submission has also been sent securely to Dr. Nicole.