Entrepreneur Wellness Assessment Form 
Welcome to The WELL Entrepreneur Wellness Program. We'd like to thank you for your interest in our wellness services. Our aim is to provide our clients with individualized wellness programs that are tailored to meet their unique needs as an entrepreneur. The questions below will help us get a better understanding of your wellness needs, challenges and barriers. 
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Email *
Name *
Phone Number *
Email *
What are current wellness goals?  Choose all that apply. *
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Why is being well a necessity for you as a business owner?  *
Do you believe you are one of your businesses best assets?  *
Do you struggle with time management? 
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Are you ready to make the financial investment to hire our wellness expert? 
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When are you looking to start working with our wellness expert? 
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Where did you learn about our wellness program The WELL Entrepreneur? 
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Have you ever worked with an entrepreneur wellness coach?  *
On a commitment scale of 1-10, 10 being the highest are you ready to put in the work required to improve your wellness? 
Do you have any health conditions that require you to be under a physician's care? 
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How many hours of sleep do you get per night? 
How much time do you spend per day on social media or your digital devices? 
A copy of your responses will be emailed to the address you provided.
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