Please select the answer(s) below that best describes the situation you are dealing with right now
Alcohol or another substance(s) is a problem I need to deal with
My marriage/relationship is on the rocks
My job/career is not what I desire it to be
Stress, fear, and worry are causing problems for me
Who else are you currently speaking with about this?
therapist
pastor
friend(s)
partner/spouse
nobody
How many hours of sleep are you getting each night?
8-10
6-7
4-5
it varies
not enough
How would you describe your food intake?
very healthy
somewhat healthy
not very healthy
not healthy at all
How often do you currently exercise?
3-5 times a week
1-2 times a week
practically not at all
How do you honestly feel about yourself right now?
I feel good about me, I'm proud of me
I have moments of feeling good about me, but they don't last
I often feel like I am failing
I don't feel good about myself at all
Approximately how many books per month do you read
5 or more
3-4
1-2
practically none
Choose the answer below that best describes your age
20-29
30-39
40-49
50+
What's your first name?
What's your last name?
What's your email address?
What's your phone number?