Pre Questionnaire for Schools, Organizations & Businesses Name: Email: Phone #: Job Title: Employer: How did you hear about us? Rate the following as it applies to you: 10 highest (This is NOT a problem in my life. I'm doing really well with this.) 5 mid (This is SOMEWHAT of a problem in my life.) 1 lowest (This is a BIG problem in my life. I’m not doing well with this.) Motivation Happy at Work Feeling Lonely Health & Wellness Education Happy at Home Self Esteem Exercise 3x/week Happy with co-workers Resolving Conflicts Body Pain Meditating Daily Depression/Sadness Stress/Anxiety Completing tasks on time Communication Issues Tired/Fatigued Advancing professionally Achieving Goals Negative attitudes Organizational skills Following Protocol Mental Focus Supporting others Paying Personal Bills Confidence Time Management Keeping Commitments Leadership Skills Lacking in Purpose Planning our Future Teamwork Being Positive Learning Life Skills How long have you had these challenging issues? When the issue is at its worst, how does it affect your team? Does this cause: MoodinessDistractionsLack of ProductivityFrustration Does this affect your team's: AttitudeEfficiencyQuality of WorkTeam Morale Have you ever had a Self-Leadership, Life Skills or Wellness Workshop? YesNo If so, when? How many? If we could improve the mental, physical and emotional wellness of your team would you want to?YesNo
