Adult Wellness Assessment
Preferred Name
First Name
Last Name
Email
example@example.com
Emotional Wellness
Ability to regulate and cope with your emotions and feelings, ability to experience attachment, and awareness of self.
I am able to express and regulate my feelings and emotions.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to functionally cope with stress and challenges.
Please Select
Never
Rarely
Sometimes
Usually
Always
I accept who I am regardless of other people’s beliefs.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to ask for help from loved ones or professionals when necessary.
Please Select
Never
Rarely
Sometimes
Usually
Always
I have a functional relationship with food, substances, and other addictive behaviors.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able and willing to create and maintain boundaries to protect myself and those around me.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am open to and pursue personal growth.
Please Select
Never
Rarely
Sometimes
Usually
Always
I feel in control of my life.
Please Select
Never
Rarely
Sometimes
Usually
Always
I enjoy my life.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to be accountable for my words and actions.
Please Select
Never
Rarely
Sometimes
Usually
Always
Emotional Wellness Total
Social Wellness
Participation in relationships with friends, family, community; sense of belonging and desire to connect.
I feel accepted by friends, family, and my community.
Please Select
Never
Rarely
Sometimes
Usually
Always
My identity is respected.
Please Select
Never
Rarely
Sometimes
Usually
Always
I feel a sense of belonging within my community.
Please Select
Never
Rarely
Sometimes
Usually
Always
I reach out to friends and make plans with them frequently.
Please Select
Never
Rarely
Sometimes
Usually
Always
I enjoy having a diverse group of individuals in my life.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to connect to others and feel safe sharing my emotions and experiences.
Please Select
Never
Rarely
Sometimes
Usually
Always
I feel like other people want to be around me and care about me.
Please Select
Never
Rarely
Sometimes
Usually
Always
I have at least one person who I can go to when I’m experiencing something difficult or tough.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to empathize with others.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to communicate with others in a way that is comfortable for me.
Please Select
Never
Rarely
Sometimes
Usually
Always
Social Wellness Total
Environmental Wellness
Stability, safety, cleanliness of your living, leisure, and workspaces; access to basic needs and comfort.
I feel safe where I live.
Please Select
Never
Rarely
Sometimes
Usually
Always
I know where I will sleep every night.
Please Select
Never
Rarely
Sometimes
Usually
Always
I have my own space where I feel comfortable.
Please Select
Never
Rarely
Sometimes
Usually
Always
I do not worry about my privacy or the safety of my belongings.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to keep my space clean and organized.
Please Select
Never
Rarely
Sometimes
Usually
Always
I have access to clean air, food, and water.
Please Select
Never
Rarely
Sometimes
Usually
Always
I have a consistent source of heating or cooling when necessary.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to sustain housing in a location that is meant for habitation.
Please Select
Never
Rarely
Sometimes
Usually
Always
I keep my spaces free of mold, spoiled food, or other health risks.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am safe from mistreatment, violence, abuse, and other dangers.
Please Select
Never
Rarely
Sometimes
Usually
Always
Environmental Wellness Total
Physical Wellness
Stability in relevant health markers, access to and use of healthcare, comfort and safety in one’s own body and identity.
I feel comfortable in my body.
Please Select
Never
Rarely
Sometimes
Usually
Always
My internal experience matches my external experience in a way I can cope with.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am physically stable and not experiencing any dysfunction in major organs.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to safely and functionally participate in exercise with the intent to improve my health and not to change my body.
Please Select
Never
Rarely
Sometimes
Usually
Always
I maintain healthcare insurance and go to any necessary appointments.
Please Select
Never
Rarely
Sometimes
Usually
Always
I take any over the counter or prescription medications as needed and directed.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to maintain balanced nutrition and proper hygiene.
Please Select
Never
Rarely
Sometimes
Usually
Always
I consume an appropriate amount of food and water.
Please Select
Never
Rarely
Sometimes
Usually
Always
I protect myself with vaccines, utilize preventative care and maintenance, and practice safe intimacy.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to seek professional help when necessary.
Please Select
Never
Rarely
Sometimes
Usually
Always
Physical Wellness Total
Financial Wellness
Sense of security and stability in money institutions (bank, credit, debt, loans, cash); ability to track, budget, and monitor own finances; availability and accessibility of cash and other assets.
I have a handle on my current finances.
Please Select
Never
Rarely
Sometimes
Usually
Always
I know that if I have an emergency, I have funds to pay for it.
Please Select
Never
Rarely
Sometimes
Usually
Always
I do not worry about being able to pay my bills.
Please Select
Never
Rarely
Sometimes
Usually
Always
I have access to a safe and secure place to store my money and assets.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to create and maintain a budget.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am knowledgeable about finances in general.
Please Select
Never
Rarely
Sometimes
Usually
Always
I do not have extensive debt or loans.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am capable of filing my taxes.
Please Select
Never
Rarely
Sometimes
Usually
Always
I feel stable enough with my finances to spend money on leisure.
Please Select
Never
Rarely
Sometimes
Usually
Always
I have a consistent stream of funds or income.
Please Select
Never
Rarely
Sometimes
Usually
Always
Financial Wellness Total
Occupational Wellness
Participation and meaningful purpose in work, access to necessary tools for job search and securing.
I am able to gain and maintain stable employment.
Please Select
Never
Rarely
Sometimes
Usually
Always
I feel my work complements my values and beliefs.
Please Select
Never
Rarely
Sometimes
Usually
Always
I feel valued and appreciated in my work.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to balance work and personal time.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am confident that I can make enough money to sustain my life.
Please Select
Never
Rarely
Sometimes
Usually
Always
I feel like my work gives me meaningful purpose in life.
Please Select
Never
Rarely
Sometimes
Usually
Always
I have access to tools and resources to grow my skills.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am open to learning new skills to further my career.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to be productive in my work.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am confident in promoting my skills and abilities.
Please Select
Never
Rarely
Sometimes
Usually
Always
Occupational Wellness Total
Spiritual Wellness
Finding meaning and purpose, a belief in something other than the self.
I feel a connection to something other than myself.
Please Select
Never
Rarely
Sometimes
Usually
Always
I believe in something bigger than myself.
Please Select
Never
Rarely
Sometimes
Usually
Always
I lead my life and choices in accordance with my personal beliefs and values.
Please Select
Never
Rarely
Sometimes
Usually
Always
I feel that I have a purpose in my life that guides my actions.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to understand the meaning of life for myself and those around me.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to celebrate life.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am open to learning about beliefs and values different from my own.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to take inventory of who and what is important to me.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to express gratitude for the people and things in my life.
Please Select
Never
Rarely
Sometimes
Usually
Always
I understand and feel a connection to all living things.
Please Select
Never
Rarely
Sometimes
Usually
Always
Spiritual Wellness Total
Intellectual Wellness
Access to learning and skill-building, a balance of street and/or book smarts.
I am confident and content with my skill set.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am willing to listen to and learn from others.
Please Select
Never
Rarely
Sometimes
Usually
Always
I desire to gain new skills and knowledge.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am able to go about the world in an efficient and productive manner.
Please Select
Never
Rarely
Sometimes
Usually
Always
I feel successful in activities and hobbies that I partake in.
Please Select
Never
Rarely
Sometimes
Usually
Always
I have an open mindset.
Please Select
Never
Rarely
Sometimes
Usually
Always
I am aware of how I learn best.
Please Select
Never
Rarely
Sometimes
Usually
Always
I enjoy spreading information about topics that I relate to and have an interest in.
Please Select
Never
Rarely
Sometimes
Usually
Always
I seek out stimulating conversation and discussion.
Please Select
Never
Rarely
Sometimes
Usually
Always
I like to give feedback to and receive feedback from others in order to learn and grow.
Please Select
Never
Rarely
Sometimes
Usually
Always
Intellectual Wellness Total
Submit
Should be Empty: