Pre Questionnaire for Schools, Organizations & Businesses

    Phone #:
    Job Title:
    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.)
    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
    Completing tasks on time
    Communication Issues
    Advancing professionally
    Achieving Goals
    Negative attitudes
    Organizational skills
    Following Protocol
    Mental Focus
    Supporting others
    Paying Personal Bills
    Time Management
    Keeping Commitments
    Leadership Skills
    Lacking in Purpose
    Planning our Future
    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