Name * First Name Last Name Email * I am happiest when... Little things that give me joy are... I am driven by... My biggest obstacles to my wellness are... How have you contributed to the obstacles that you face regarding your wellbeing? Which of the following are challenges to you personally? Check all that apply Consistency + Motivation Self-Sabotage Time Management Stuck in my own head Self-judgement & judgement (caring what other people think) Addiction (Food, Alcohol, Cannabis, Sex, Internet/Social Media, etc.) Lack of personal accountability I deeply love and respect the person that I am. Strongly Disagree Disagree Neutral Agree Strongly Agree I place more weight on self-expectation than the expectations of others. Strongly Disagree Disagree Neutral Agree Strongly Agree Health and wellness is something that I prioritize. Strongly Disagree Disagree Neutral Agree Strongly Agree I have previously experienced success or growth with regard to my health and wellness. Strongly Disagree Disagree Neutral Agree Strongly Agree I feel a strong sense of purpose. Strongly Disagree Disagree Neutral Agree Strongly Agree I am a part of a community or friend group in my local area. Strongly Disagree Disagree Neutral Agree Strongly Agree I participate in hobbies and interests outside of work. Strongly Disagree Disagree Neutral Agree Strongly Agree I believe I have the ability to change. Strongly Disagree Disagree Neutral Agree Strongly Agree I am a human being that could use support with... Thank you!
