First Name
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Last Name
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Phone
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Email
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How would you rate the quality of your sleep currently? (1 = Poor; 10 = Excellent)
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1
2
3
4
5
6
7
8
9
10
How many hours do you sleep on average per night (time spent asleep NOT time spent in bed)?
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< 5
5-6
6-7
7-8
8+
Do you go to bed at a consistent time every night?
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Always
Sometimes
Rarely
Never
Please describe your nightly routine/habits in the hour prior to sleep
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How would you rate the level of stress in your life right now? (1 = No Stress; 10 = Chronic stress)
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1
2
3
4
5
6
7
8
9
10
Do you ever feel that you’ve been affected by feelings of edginess, anxiety, or nerves?
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Yes
No
Unsure
Have you ever experienced a week or longer of lower-than-usual interest in activities that you usually enjoy? Examples might include work, exercise, or hobbies.
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Yes
No
Unsure
What are your current sources of stress and why are they stressful?
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How long have you been feeling stressed out and overwhelmed?
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1 - 4 Weeks
1 - 6 Months
6 - 12 Months
Over a year
What are your long term goals when it comes to stress management and your overall health?
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What do you think is your #1 challenge when it comes to achieving those goals?
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How committed are you to solving your stress problem? (1 = Not at all. 10 = Fully Committed)
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1
2
3
4
5
6
7
8
9
10
"If someone advised me to spend $400-$1000 on my health & wellness, I would..."
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Know it's an important part of managing my stress levels, and would do it with the the right accountability and system to follow
Would be a little intimidated, yet with a proven system I would do it because I do want to invest in my health
Avoid it, as I am looking for cheaper ways to manage my stress
Please describe how you invest in your health and wellness
Are you ready to book a 30 min call within the next 72 hours to see if you're a good fit for our program? Please do NOT book unless you're genuinely interested in making a lifestyle change, as these time slots are valuable to those we help.
Yes
No