As a direct result of the services I received at Wellness Center Central:

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* 1. Date

Date

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* 2. Member Number

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* 3. I participate in more social activities in my community.

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* 4. I am better able to deal with crisis.

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* 5. I am getting along better with my family.

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* 6. I do better in social situations.

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* 7. Employment - I am more interested in work.

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* 8. I have gained employment.

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* 9. Education - I am more interested in furthering my education.

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* 10. I have enrolled in an educational institution.

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* 11. Volunteerism - I am more interested in volunteering.

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* 12. I am now volunteering in the community.

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* 13. I do better in school, work and/or volunteering.

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* 14. My symptoms are not bothering me as much.

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* 15. I do things that are more meaningful to me.

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* 16. I am better able to take care of my needs.

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* 17. I am better able to handle things when they go wrong.

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* 18. I am happy with the friendships I have.

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* 19. I have people with whom I can do enjoyable things.

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* 20. I feel I belong in the community.

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* 21. Please name group(s) that have been helpful to improve your quality of life as listed above.

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