Evening Reflection Survey
Reflect on your day, assess your well-being, and set intentions for tomorrow.
Date of Reflection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Overall, how would you rate your mood today?
*
1
2
3
4
5
Please indicate your agreement with the following statements about today:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I accomplished what I set out to do
1
2
3
4
5
I managed stress effectively
6
7
8
9
10
I felt connected to others
11
12
13
14
15
I took care of my physical health
16
17
18
19
20
What was the highlight of your day?
What challenge did you face today?
How grateful did you feel today?
*
Not at all
1
2
3
4
5
6
7
8
9
Extremely grateful
10
1 is Not at all, 10 is Extremely grateful
Which of the following did you practice today? (Select all that apply)
Mindfulness
Exercise
Acts of kindness
Healthy eating
Journaling
Other
What is one thing you learned today?
How would you rate your stress level today?
*
No stress
1
2
3
4
5
6
7
8
9
Extremely stressed
10
1 is No stress, 10 is Extremely stressed
What is your intention for tomorrow?
Any additional comments or reflections?
Submit Reflection
Should be Empty: