Wellness Check-In Form

1

Full Name* This field is required.

First Name

Last Name

2

Email

example@example.com

3

As I think about the school year ahead, I already feel pressure to manage everything that will be expected of me.* This field is required.

0-Not at All

1 - A Little

2 - Quite a Bit

3 - Very Much

4 - I Can't Even Sleep At Night

4

I worry that maintaining healthy boundaries between work and my personal life may become difficult as the year gets busier.

0 - Not at All

1 - A Little

2 - Quite a Bit

3 - Very Much

4 I Can't Even Sleep At Night

5

When I think about the months ahead, I am concerned about having enough time and energy to take care of myself while supporting everyone else.

0 - Not at All

1 - A Little

2 - Quite a Bit

3 - Very Much

4 - I Can't Even Sleep At Night

6

I can already identify situations, responsibilities, or expectations that may become sources of stress for me this school year

0 - Not at All

1 - A Little

2- Quite a Bit

3 - Very Much

4 - I Can't Even Sleep at Night

7

I feel like I need a clear plan for protecting my joy, energy, and emotional wellness before the demands of the school year increase.

0 - Not At All

1 - A Little

2 - Quite a Bit

3 - Very Much

4 - I Can't Even Sleep at Night

8

Having a consistent space to reflect, reset, and connect with other educators would help me feel more supported throughout the school year.

0 - Not at All

1 - A Little

2 - Quite a Bit

3 - Very Much

4 - I Can't Even Sleep at Night

9

Wellness Score TEST RESULTS WILL BE EMAILED