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