Non Profit, Community Organization Wellness Program Intake Form

Non Profit, Community Organization Wellness Program Intake Form

Share your motivations, challenges, and goals so we can best support your organizations journey.
Welcome

Thank you for taking the time to complete this intake form. The fact that you are exploring a wellness program tells me you care deeply about your staff and the long-term health of your organization.

Supporting the people who carry the mission every day is not a small decision. My goal is to understand what matters most to you so we can create something practical, supportive, and truly beneficial, not just another initiative, but a meaningful investment in the energy, clarity, and resilience of your team.
Your Name*

First NameLast Name
Email
example@example.com
What is the name of your organization?
What prompted you to explore a workplace wellness program at this time? Is this initiative connected to a strategic plan, grant requirement, retention effort, or leadership priority?*
What are your top 3 outcomes you hope this program will support?(e.g., retention, morale, productivity, reduced sick time, team cohesion)

RetentionMoraleProductivitySick timeTeam cohesionOther
If Other please elaborate here
What are the biggest stressors your team is facing?*
How many employees would participate?

1-55-1010-1515 or moreOther
What is your preferred method of delivery?

In-personHybridTotally virtual
How would you like it delivered?

On hour once a week for 8 weeks2 hours once a week for 4 weeks4 hours once a week for 2 weeksOther
Is there a preferred time?

MorningAfternoon
Are there cultural, physical, or accessibility considerations we should be aware of?

yesnoCulturalPhysicalAccessibilityOther
Would ongoing check-ins be valuable after the program concludes?

yesnoA 1:1- 30 min call for each participant to ask confidential questions30 days after the program is over a group check inQuarterly check ins and new resources
This is the quiet make-or-break. How committed is leadership to modeling and supporting wellness behaviors? (If leadership won’t show up or support the initative, the staff won’t either. We all know how that goes.)

verysomewhatnot a priority
Is Leadership going to participate?

YesNo
Is there a budget allocation for this program?

yesNo
Is there anything else you’d like us to know to best support your organization during this program?
Should be Empty: