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* 1. First and Last name:

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* 2. Email:

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* 3. What is your gender identity?

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* 4. Affiliation:

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* 5. School/Division

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* 6. How did you hear about Wellness Coaching?

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* 7. Which Facet(s) of Wellness would you like to focus on?

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* 8. Among the list below, please indicate what you would like to work on with your Coach (check all that apply):

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* 9. What are your biggest changes you want to make in your life in the next 3 months?

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* 10. What do you feel stops you from achieving these changes?

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* 11. Please indicate the best days and time frames for your first Coaching session.  A Coach will then contact you to confirm the day and time of your first session.  Please indicate all that apply.  If none of these days/times work for you, please indicate a day/time that would work best for you in the "other" field.

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Wednesday
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