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* 1. First and Last name:

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* 2. Email:

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* 3. Preferred pronouns?

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* 4. Affiliation:

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* 5. School/Division:

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* 6. Are you currently enrolled at UChicago?

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* 7. Have you participated in Group Wellness Coaching on campus?

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* 8. If so, which group were you a part of?

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* 9. How did you hear about Wellness Coaching?

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* 10. Which Facet(s) of Well-being would you like to focus on?

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* 11. Your top three priorities for your work with a wellness coach are:

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* 12. Please answer the following:

  Never Rarely Sometimes Frequently Most of the time
I feel a strong sense of purpose in life.
I feel a deep satisfaction or joy in my life.
I feel a sense of satisfaction in my academic/job performance.
I feel a sense of gratitude and appreciation for what I have.
I feel a sense of satisfaction in my personal relationships.

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* 13. How do you feel you are coping with your current stress load?

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* 14. Mark any symptoms of stress that apply to you:

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* 15. During the past four weeks, to what extent have you accomplished less than you would like in your work or other daily activities as a result of emotional issues, such as feeling stressed or anxious?

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* 16. Please answer the following about how you have been feeling in the last four weeks:

  None of the time A little of the time Some of the time Much of the time All of the time
Have you felt calm and peaceful?
Did you have a lot of energy?
Have you been a happy person?
Did you take time to relax and have fun daily?
Have you felt downhearted or blue?
Have you felt worthless, inadequate, or unimportant?

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* 17. If you answered "some of the time" or higher for the last two questions in #15, please complete the below:
Over past two weeks, how often have you:

  None or little of the time Some of the time Most of the time All of the time
Been feeling low in energy, slowed down?
Been blaming yourself for things?
Had a poor appetite?
Had difficulty falling asleep, staying asleep?
Been feeling hopeless about the future?
Been feeling blue?
Been feeling no interest in things?
Had feelings of worthlessness?
Thought about or wanted to complete suicide?
Had difficulty concentrating or making decisions?

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* 18. How many hours of sleep do you get on average?

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* 19. Do you have friends/family with whom you can share problems and get help if needed?

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* 20. Please select the top three things that boost your energy:

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* 21. Please select the top three things that drain your energy:

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

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

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* 24. My readiness to make changes or improvements in my life is:

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* 25. Before completing this registration form:
1. Please schedule your first sessions here
2. Complete the VIA Strengths Assessment. No purchase is necessary.  
*NOTE: PLEASE DO NOT FORGET TO SUBMIT THIS REGISTRATION FORM ONCE YOU HAVE COMPLETED THE VIA ASSESSMENT AND SCHEDULED YOUR FIRST SESSION*

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