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