7 Dimensions for Wellness Coaching Assessment
Thank you for completing this form. This will help us to assess how we can map our your support and resources. Please be honest. Completely answer the questions. This should take you approx 10 -15 minutes.
Email address *
Name *
Age
Phone number
Zip Code *
Are you Hispanic or Latino? *
What language are you most comfortable speaking? *
Which race(s) are you? Check all that apply. *
Required
Gender *
Do you consider to be?
How many family members, including yourself, live with you? This helps to determine benefits. *
In the past year, have you or any family members you live with being unable to get any of the following when it was really needed? Check all that apply. *
Required
Has a lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply. *
Required
Do you feel physically and emotionally safe where you currently live? *
How often do you see or talk to people that you care about and feel close to? (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings) *
Income Level *
Education Level *
Housing *
Do you have a felony conviction? We ask so we know what services we need to access? *
Do you live with a disability? *
What is your current work situation? *
Have you been discharged from the armed forces? *
What is your main insurance? *
Tell us about your physical health. Check the items you need help with. *
Required
Tell us about your emotional health. Check the items you need help with. *
Required
What specific assistance or coaching are you needing from us? *
Thank you for completing the form. Please allow for 48-72 hrs for a reply. If this is an emergency, please call 911.
You will be contacted via email and phone. Thank you
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