Commit to be Well Application 2019
What is Commit to be Well?
An eight weeks program designed to support ASU students, faculty and staff as they work with a Health and Wellness Coaching trainee to improve their well-being in all aspects of their life while utilizing ASU Wellness and Academic resources. All students, faculty and staff can apply. You will be notified if you are selected for our program!

What is Health & Wellness Coaching?
Health and Wellness Coaches will partner with Commit to be Well participants who are seeking self-directed, lasting changes and will assist them in aligning their wants and values to enhance their well-being. A Health and Wellness Coach is NOT a personal trainer! For more details about what is health and wellness coaching please review this document (

Spring 2019 (February 25 until April 21)

Time Commitment
Throughout the eight weeks, participants will meet telephonically or via video conference with their health coaches at least three times. One initial coaching session to establish participants wellness vision, long term, and short term goals and two follow up coaching sessions. Participants will also be given access to ASU Wellness resources. Health and wellness coaches will encourage you to participate in a variety of wellness activities as needed.

By filling out this application, you are in the running to be chosen as a participant in Commit to be Well. Being chosen for this program is not a reflection of your current fitness or wellness level as we are more interested in your goals and your responses to the application questions.

The selected individuals will receive a variety of wellness programs and activities for free, but will be asked to adhere to preset expectations throughout the eight weeks (see below). Your progress will be tracked by your coach through the program.

The following are minimum expectations for all Commit to be Well participants. It is important that you follow-through with all expectations, and also take advantage of other free wellness services provided in order to reach your wellness goals.
o Participate in the full eight weeks.
o Complete an initial coaching session to establish a wellness vision, short term, and long-term wellness goals (60-90 min, in person or phone)
o Meet with health coach for two follow-up sessions and monitor goal progress (20-30 min, in person or phone)
o Attend at least one group class

By completing and submitting this application, I agree to adhere to the prior expectations.

This application is due by February 21, 2019. Applicants will be notified by February 22 if selected to be a part of Commit to be Well. For additional questions please contact Nikita Thomas through email at
Email address *
Full Name & Last Name *
Phone Number *
Is it OK to text your phone number? *
Age *
Date of Birth *
Gender *
I am a(n) *
If an undergraduate, what year? *
What is your major? If not a student write NA *
Primary campus location is *
What is your College/School? *
Health Screening Questions *
Has your doctor ever told you that you have a heart condition and you should only do physical activity recommended by a doctor?  
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not actively involved in physical activity?
Do you lose your balance because of dizziness or have you ever lost consciousness?
Do you have a bone or joint problem that could be made worse by change in your physical activity?
Is your doctor currently prescribing drugs for your blood pressure or a heart condition?
Do you know of any other reason why you should not do physical activity?
Currently, how would you describe your overall health? *
These areas below are core to sustaining our health and well-being. On a scale of 1 – 10 with 10 being the most positive and highly satisfied, how would rate your satisfaction today? Please rate your satisfaction with the following areas of your life.
SELF-RESPONSIBILITY & LOVE: discovering your real needs, finding ways to meet them directly and listening to your own heart ---Realizing that you are unique and the expert about yourself, and treasuring your uniqueness and your inner wisdom. Realizing your connectedness with all things. Consistently getting adequate restful sleep as well! *
BREATHING: Are you aware of your breathing patterns and use it as a stress protective activity? *
SENSING: It is through the senses--seeing, touching, smelling, hearing, tasting--that we come to know and enjoy the world. Are you fully aware of your senses? *
EATING/NUTRITION: Do you eat whole minimally - processed nutritious foods? *
MOVEMENT: Do you feel that physical activity helps improve your overall health and fitness while reducing our risks for many chronic diseases and protecting against stress? *
FEELING: For any given event, we respond by both feeling and thinking. Are you mindful about our feelings?  *
THINKING: Do you acknowledge the crucial power of thinking in your well-being? *
PLAYING & WORKING: It is important to recapture the spirit of play that can bring balance into our lives. When you feel burdened with work and responsibilities do you find some time to play? *
COMMUNICATING: Are you aware of the clarity in your communications and the possibilities for meaningful encounters when interacting openly?  *
INTIMACY/RELATIONSHIPS: Do you recognize that healthy socializing and relationships are essential to healthy living? *
FINDING MEANING / SPIRITUALITY: Do you acknowledge and honor the role of spirituality (purpose and meaning) in your health? *
TRANSCENDING: Are you aware of the values and beliefs about yourself & the world? Do you experiencing your connection to something greater than yourself? *
LOVE IN LIFE: Identify what you truly love in life and how you want to be in life. What makes you thrive? ~ When are you most alive and fully engaged? *
Consider beginning with I love to do… I love to be… I love to feel…
HEALTH & WELL-BEING: Let yourself understand why you value your health and want to be healthy. Visualize what being healthy allows for your life. What kind of person do you want to be when it comes to your health and well-being? ~ What are you currently doing to support your health and well-being? *
Complete the sentence: I want to improve my health and well-being because...
OPTIMIZING HEALTH & WELL-BEING: What are the benefits of making changes now? What is the driving force behind the desire change now? What do you treasure most about potential change? *
Reflect on this statement: The reason I want to take good care of myself is so I can... so I feel...
Have you participated in Commit to be Well in the past? *
Why are you interested in participating in the Commit to be Well program and how will it support your well-being? *
Would this be your first health and wellness coaching experience? *
Do you understand the role of a health and wellness coach in assisting you in enhancing your well-being and honoring that you are an expert on your life? *
What day/time is best to connect with your coach? You may select more than one option a day. Scroll to the side to see all the time options. If you are an online student, when selecting the time that works for you, please select the time that reflecs your time in Arizona time. *
Before 9 am
After 9pm
Based on your availability, you will be matched with a student coach to complete your telephonic/videoconference health and wellness coaching sessions. Do you have any specific comment/request from us?
Would you like to participate in an orientation session to review the expectations of the Commit to be Well Program, the role of the Health and Wellness Coach, and resources available to you? *
If interested in an orientation, session please select your preferred times and days. You can only choose one time a day (please do this time in Arizona time). *
9 am -12 am
12 pm -3 pm
3 pm - 6 pm
After 6 pm
Any time on this day
Not available this day
Not interested in orientation
Do you have any questions right now that you want us to address before you start Commit to be Well? *
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