Personal & Career Wellness Assessment

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Agency or Organization Name *

What topics regarding personal and career planning are of interest to you?

Select all that apply.

Developing a Monthly Financial Plan

Tackling Debt

Investing for College and/or Retirement

Strengthening Family Relationships

Coping with Personal and Career Stress

Improving Quality of Life

Other:

Are you suffering from any of the following due to financial, job, or personal stressors?

Losing Sleep

Gaining or Losing Excessive Weight

Not Exercising

Strained Relationships

Misuse of Alcohol or Drugs

Suffering Depression, Anxiety or Anger

Lack of Motivation at Work or Home

Weakening of Faith

Are you completely at peace about your financial future?

Yes

Clear selection

Would you say you live paycheck to paycheck most months of the year?

Yes

Clear selection

Have you ever borrowed money from a friend, relative or retirement account?

Yes

Clear selection

Which of the following best describes your current feelings about personal and career life?

Everything is great at home and I love my job!

I am needing minor improvement in an area or two.

I am struggling in one or more specific areas.

I'm really not too excited about life in general.

I'm afraid to admit it, but I think I'm in crisis mode.

Clear selection

Would you like for your employer to offer more education in the above areas?

Yes

Clear selection

Which training topics would you like to see offered?

Check all that apply

Financial Education

Crisis Management

Stress Reduction

Peer Support

Formal Mentoring Program

Leadership Development

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