Thank you for completing this 10 item form.

With each item consider how things are today, at this moment.  Your responses may vary each time you complete the form.  Some items may not make sense or apply to you at this time, no worries.  Simply let us know.  We appreciate your candid feedback. 

Additional comments are NOT required but we always enjoy hearing from you.  

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* 1. What is your first name?

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* 2. Do you have a personal vision of your best health?

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* 3. Do you have a focus for health behavior change?

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* 4. Have you set your goal(s) inline with your focus and vision?

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* 5. Do you have clear actions to assist with exploring your goal(s)?

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* 6. Do you believe you are capable of working towards and achieving your goal(s)?

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* 7. Do you learn and develop new insights about your health behaviors as you take action towards your goal(s) each week?

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* 8. Are you motivated to take action towards your goal(s)?

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* 9. Is POE Women for PD supporting you in making positive, lasting behavior change?

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* 10. Use this space to provide additional comments to support and improve the services provided by POE Women for PD.  

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