Be Well Institute Interest Form
This survey will be used to help tailor a curricular package to best suit your wellness needs.
Email address *
Sleep Habits *
How do you feel when you wake up in the morning? Check all that apply
Hours of Sleep *
How many hours of sleep do you get on average per day?
Academic (complete only if in school)
Would you describe yourself as a good student?
On Average, how frequently do you get sick and miss school/or work?
Weight *
Are you comfortable at your current weight? Use the answer that best describes your current feelings.
List vegetables you typically eat
List all the fruits you typically eat
What would like the most support with as you work to obtain more optimal wellness?
Your answer
What are your areas of stregth that will support you as you work to obtain more optimal wellness?
Your answer
I will contact you by email to set up a phone call about how the Be Well institute can support your needs. If you would like me to call you directly to set this up, please include your phone number here.
Your answer
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