The intention of this survey is to provide you the space to self-reflect on your current health and wellness. Joining R2R requires an honest level of self-reflection and dedication to an intentional wellness journey. 

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* 1. First Name

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* 2. Last Name

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* 3. Age

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* 4. Which gender identity do you most identify with?

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* 5. Which ethnicity do you most identify with? (Please select only one)

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* 6. Preferred Phone Number (xxx-xxx-xxxx)

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* 7. Preferred Email Address

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* 8. Street Address 

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* 9. Apartment/Suite Number

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* 10. City

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* 11. State

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* 12. Zipcode

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* 13. I currently have active health insurance.

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* 14. I am familiar with the term Adverse Childhood Experiences (ACEs).

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* 15. I know my ACE score.

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* 16. What interests you in joining Rise to Resilience (R2R)?

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* 17. What does a healthy lifestyle look like for you?

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* 18. What do you currently do to take care of you and your health?

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* 19. In thinking about your health, wellness, and healing what would you like to improve and/or learn?

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* 20. Looking inward, how satisfied are you with the following areas of your life

  Not Satisfied  Barely Satisfied Somewhat Satisfied Very Satisfied Extremely Satisfied
Sleep
Nutrition
Physical Activity/Exercise/Body Movement
Relationships
Play (fun engaging activities out of ones comfort zone)
Self-Exploration (opportunities to learn more about myself)
Mindfulness (awareness of thoughts/feelings/emotions and react with intention)
Emotional intelligence/emotional healing

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* 21. How many hours of sleep do you get a day/night?

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* 22. How often do you engage in a minimum of 20 minutes of physical activity?

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* 23. How often do you engage in play/fun activities that bring joy to your life? 

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* 24. How often do you eat a nutritious meal?

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* 25. Please rate your level of agreement with this statement: "I create and maintain healthy relationships."

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* 26. Looking inward, please rank your level of commitment to strengthening the following areas of your life:

  Not at all Committed Slightly Committed Somewhat Committed Committed Very Committed
Sleep
Nutrition
Physical Activity/Exercise/Body Movement
Relationships
Play (Fun engaging activities out of ones comfort zone)
Self-Exploration (Opportunities to learn more about myself)
Mindfulness (Awareness of thoughts/feelings/emotions and react with intention)
Emotional intelligence/emotional healing

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* 27. Which areas of your life would you like more support in strengthening? (Select all that apply)

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* 28. Please rate your level of agreement with this statement: "I am comfortable sharing my thoughts, feelings, and opinions with others."

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* 29. Once you submit this interest form you will be contacted by a R2R Squad member to schedule an individual orientation.

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