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* 1. Your full name:

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* 2. Your email:

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* 3. Your UChicago affiliation:

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* 4. Expected number of attendees:

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* 5. School/division of your group:

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* 6. Please tell us some information about your audience (e.g., first-year students living in Max Palevsky, Harris graduate students, student RSO leaders, Booth academic advisers, etc.):

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* 7. How many group wellness coaching sessions do you anticipate having for your group? (Please note each session will last between 60-75 minutes and tend to be a week or two apart)

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* 8. Date and time of session(s):

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Date
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* 9. Location (building, room number):

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* 10. What are your goals for group wellness coaching? What do you hope the participants will gain by attending?

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* 11. Is there a specific topic you would like the group to focus on (self-care, time management, healthy habit formation, etc.)?

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* 12. Other details or comments:

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