R3 Vitals Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Gender
Please Select
Please Select
Male
Female
N/A
4
Country of Residence?
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
5
Area of Work* This field is required.
Please Select
Please Select
Business Owner
Contracted Ministry Worker
Executive Leadership
Finance/Operations
Full-time Pastor
Management
Ministry Leader/Director
Music/Production
Other
6
How have you been feeling lately?* This field is required.Select all the apply.
Optimistic
Confident
Joyful
Loving
Positive
Grateful
Accepted
Hopeful
Blessed
Calm
Content
Valued
Respected
Fearful
Cautious
Anxious
Dread
Timid
Insecure
Threatened
Uneasy
Unhappy
Depressed
Discouraged
Burned Out
Isolated
Ashamed
Hurt
Grief
Guilty
Wronged
Bored
Critical
Upset
Frustrated
Insulted
Furious
Hostile
Pressured
Stressed
Curious
Motivated
Passionate
Excited
7
Spiritual Domain* This field is required.Your view and/or relationship with God (understanding/belief of and intimacy with God) Rate from 1 (Strongly Disagree) to 6 (Strongly Agree)
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I feel close to God.
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I spend quality time with God most days.
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I feel connected to God as though He is my source of life.
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I never question if I really believe in God.
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I most often consider what God thinks before making decisions.
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I feel a deep sense of love when I think about God.
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I experience God in a variety of ways often.
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I feel close to God.
I spend quality time with God most days.
I feel connected to God as though He is my source of life.
I never question if I really believe in God.
I most often consider what God thinks before making decisions.
I feel a deep sense of love when I think about God.
I experience God in a variety of ways often.
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Personal Domain* This field is required.Your view and/or relationship with self (identity, physical, mental, and emotional health) Rate from 1 (Strongly Disagree) to 6 (Strongly Agree)
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I have a positive and healthy view of self.
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I get 7-8 hours of sleep every night.
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I am very hopeful about the future.
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I rarely worry about things I cannot control.
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I am often clear minded and mentally alert.
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I regularly eat healthy and exercise.
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I experience joy and passion about life on a regular basis.
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I have a positive and healthy view of self.
I get 7-8 hours of sleep every night.
I am very hopeful about the future.
I rarely worry about things I cannot control.
I am often clear minded and mentally alert.
I regularly eat healthy and exercise.
I experience joy and passion about life on a regular basis.
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Relational Domain* This field is required.Your view and/or relationship with others (intimacy and relationship dynamics with friends/family/others) Rate from 1 (Strongly Disagree) to 6 (Strongly Agree)
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I feel there is a strong sense of connection with my closest relationships.
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I rarely feel isolated or alone.
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I receive positive energy from those I am typically around.
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Those I am closest to know me well.
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I find it easy to be appropriately vulnerable.
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I have someone in my life I can go to when I need advice.
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I am regularly mentoring someone.
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I feel there is a strong sense of connection with my closest relationships.
I rarely feel isolated or alone.
I receive positive energy from those I am typically around.
Those I am closest to know me well.
I find it easy to be appropriately vulnerable.
I have someone in my life I can go to when I need advice.
I am regularly mentoring someone.
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Vocational Domain* This field is required.Your view and/or relationship with work (calling, competency, chemistry, and compensation). Rate from 1 (Strongly Disagree) to 6 (Strongly Agree)
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I have the knowledge necessary to perform my job at a high level.
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I have the experience necessary to perform my job at a high level.
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I believe what I do matters to both God and the people I serve.
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I make enough money to contribute to what my family needs.
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I believe I am doing what I was made to do.
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I know and understand my gifts and talents.
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I have healthy and positive relationships with my colleagues and leaders.
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I have the knowledge necessary to perform my job at a high level.
I have the experience necessary to perform my job at a high level.
I believe what I do matters to both God and the people I serve.
I make enough money to contribute to what my family needs.
I believe I am doing what I was made to do.
I know and understand my gifts and talents.
I have healthy and positive relationships with my colleagues and leaders.
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Overall ScoreThe aggregate score below indicates your current state in relationship to burnout. For a more comprehensive view and recommendations/understanding based on your results, please schedule a 45-minute follow-up session at your convenience.
0-2 (Restore), 2-4 (Renew), 4-6 (Refresh)
12
Spiritual Domain Score0-2 (Restore), 2-4 (Renew), 4-6 (Refresh)
13
Personal Domain Score0-2 (Restore), 2-4 (Renew), 4-6 (Refresh)
14
Relational Domain Score0-2 (Restore), 2-4 (Renew), 4-6 (Refresh)
15
Vocational Domain Score0-2 (Restore), 2-4 (Renew), 4-6 (Refresh)
16
What does your score mean?Select a day and time to gain insights about your results and take your next step towards a better future
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