Your Wellness Planning Questionnaire Update
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Email
*
example@example.com
Review Every 30 Days
After reviewing your last wellness plan, how much progress have you made?
As of today, what has changed since you first started?
Using healthy coping skills
Decreased anxiety
Improved mood
Decreased panic attacks
Improved motivation
Socializing more
Eating healthier
Exercising more
Drinking less
Setting better boundaries
Improved communication
Laughing more
Feel more confident
Feel less distracted
Feel hopeful
Other
What things have helped you so far in your treatment?
*
(like breathing, meditation, mindfulness training, accountability, etc.)
As of today, what's your current challenge?
*
Has it changed from when you first started?
Are there any NEW problems that've come up since your last wellness plan?
Yes
No
Problem #1
(What problem do you want to focus on in your sessions?)
Problem #2
(What other problem do you want to focus on in your sessions?)
Do you want to set new wellness goals?
Yes (I'd like to set new goals or add some)
No (I'll keep working on my old goals)
Goal #1
Goal #2
Are there any other things you think are important to focus on in future sessions?
*
Check the interventions you are interested in incorporating into your treatment.
Psychotherapy
Life Coaching
Health & Wellness Coaching
Personal Training
Soul Bourn
Individual Yoga
Glow Flow Yoga
Living Well Lab (online training)
5 Week Women's Wellness Bootcamp (January)
1 Day Breaking Secrets Symposium (Spring)
2 Day Rewrite Your Story Retreat (October)
Other
Based on your progress thus far, how often do you think you need individual sessions?
Weekly
Two 60 minutes sessions a month
Two 30 minute sessions a month
One 60 minute session a month
No individual sessions
Your Signature
*
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