Health, Wellness, Relationship Assessment

  • Wellness Assessment

    Questionnaire based on the uploaded wellness assessment spreadsheet. Please answer each item as listed.
  • Format: (000) 000-0000.
  • Date
     - -

  • Lifestyle

  • Are you currently estranged or have limited contact with any of your children?*
  • Are you currently estranged or significantly disconnected from any immediate family member?*
  • Has a child or dependent moved out of your household within the past 12 months?*
  • Do you currently have any pets?*
  • Have you moved or relocated your primary residence within the past 12 months?*
  • Have you experienced any major injury, serious illness, or significant health condition that may affect your lifestyle, daily activities, or future plans?*
  • Intimacy and Relationship Compatibilitys*
  • Do you currently smoke cigarettes or use nicotine products?*

  • Employment, Education

  • Have you experienced a significant financial loss or financial setback within the past 12 months?*
  • Student, full or part-time (currently)*
  • Do you generally meet your financial obligations on time?*
  • How much time do you typically spend watching television, streaming services, or online video content?*
  • Do you have any pending legal issues that may affect your participation in this program?*
  • Are you comfortable sharing your public social media profiles with the Agency for verification purposes?*
  • How often do you participate in outdoor recreational activities?*
  • How often do you participate in social activities with friends, family, or groups?*
  • How often do you participate in volunteer or community service activities?*

  • Wellness

  • Has your weight changed by more than 10 pounds (gain or loss) within the past 12 months?*
  • How would you describe your personal hygiene and grooming routine?*
  • Do you currently take any vitamins, supplements, or wellness products?*

  • Relationship

  • Terms and Conditions:

    Achieve Destiny upholds a confidential, positive, and impartial environment. All participants must be at least 18 years old and present a valid photo ID prior to the screening process. Participants acknowledge that Achieve Destiny functions as a matchmaking and counseling service. By participating, you confirm that the information provided is voluntary, accurate, truthful, and confidential. Participants are expected to behave in a respectful, responsible, and lawful manner. Cooperation with other participants and the Achieve Destiny team is required throughout the process. Any inappropriate behavior by a client will result in the termination of their non-refundable membership and services. You authorize Achieve Destiny to conduct a minimal background check.  

    While participants are prescreened, safety risks may still exist. It is essential to adhere to safety guidelines, including meeting in public places, refraining from sharing personal information, and notifying a friend or relative about your whereabouts. In case of any safety concerns, contact law enforcement immediately by calling 911. Report all safety issues or concerns to the Achieve Destiny team. Clients are solely responsible for any damages, injuries, and all legal fees incurred, including those of Achieve Destiny. All services and transactions are non-refundable.

    HIPAA Authorization and Release

    I hereby authorize Achieve Destiny, LLC, Florida Private Investigator Agency License and its authorized representatives to obtain, receive, review, and use protected health information and medical records relevant to the investigative services I have requested. I understand that this authorization is voluntary, may be revoked in writing at any time, and will remain in effect until the investigation is completed or one (1) year from the date of my signature, whichever occurs first. I acknowledge that information disclosed pursuant to this authorization may no longer be protected by HIPAA once released to an authorized recipient.

    Certification of Accuracy and Truthfulness

    I certify that all information, statements, photographs, documents, and other materials provided by me to Achieve Destiny Relationship & Investigation Agency are true, accurate, complete, and provided in good faith to the best of my knowledge and belief. I acknowledge that the Agency will rely upon the information I provide in evaluating potential matches, conducting relationship-related services, and/or performing investigative services.

    I understand that providing false, misleading, incomplete, or omitted information may adversely affect the services provided and may result in the denial, suspension, or termination of my membership, participation, or client relationship with the Agency. I further acknowledge that any intentional misrepresentation may be referred to appropriate authorities if such conduct involves fraud, identity theft, harassment, or other unlawful activity.

    By signing below, I affirm that I have answered all questions honestly and truthfully, have disclosed all information requested, and agree to notify the Agency of any material changes to the information provided.

    Expiration
    Unless revoked earlier, this authorization shall expire one (1) year from the date signed below, or upon completion of the investigative matter, whichever occurs first.

    Authorization
    I certify that I am at least 18 years of age and am legally authorized to execute this authorization.

    Client Acknowledgment and Agreement

    By signing below, I acknowledge that I have read, understand, and voluntarily agree to all terms, conditions, authorizations, disclosures, policies, and provisions contained within this agreement and related documents provided by Achieve Destiny, LLC. I understand my rights and responsibilities and agree to be bound by the terms of this agreement.

  • Date
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  • Should be Empty: