UChicago Wellness Coaching Question Title * 1. First and Last name: OK Question Title * 2. Email: OK Question Title * 3. What is your gender identity? Male Female Please specify how you wish to be identified: OK Question Title * 4. Affiliation: First Year Second Year Third Year Fourth Year Graduate Masters Graduate PhD Graduate Professional Other (please specify): OK Question Title * 5. School/Division The College Biological Sciences Booth School of Business Divinity School Division of Social Sciences Graham School Harris School of Public Policy Humanities Institute for Molecular Engineering Law School Physical Sciences Pritzker School of Medicine School of Social Service Administration Other (please specify): OK Question Title * 6. How did you hear about Wellness Coaching? SHCS Website HPW Newsletter/BustMyStress A friend Staff/Faculty Referral Email O-Week, Flyer Social Media Other (please specify): OK Question Title * 7. Which Facet(s) of Wellness would you like to focus on? Emotional Environmental Financial Intellectual Physical Social Spiritual OK Question Title * 8. Among the list below, please indicate what you would like to work on with your Coach (check all that apply): Homesickness Time Management Organization Stress Management Procrastination Relationship Issues Living Arrangements Nutrition Personal Growth Tradition Issues Family Stressors/Obligations Financial Organization Sleep Issues Physical Acitivty Communication Skills Academic Performance/Stressors Work Performance/Stressors Work/Life Balance Healthy Habit Formation/Maintenance Interpersonal Difficulties Self Confidence/Self-Esteem General Wellness Concerns OK Question Title * 9. What are your biggest changes you want to make in your life in the next 3 months? OK Question Title * 10. What do you feel stops you from achieving these changes? OK Question Title * 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. 8:00AM 9:00AM 10:00AM 11:00AM 12:00PM 1:00PM 2:00PM Monday Monday 8:00AM Monday 9:00AM Monday 10:00AM Monday 11:00AM Monday 12:00PM Monday 1:00PM Monday 2:00PM Tuesday Tuesday 8:00AM Tuesday 9:00AM Tuesday 10:00AM Tuesday 11:00AM Tuesday 12:00PM Tuesday 1:00PM Tuesday 2:00PM Wednesday Wednesday 8:00AM Wednesday 9:00AM Wednesday 10:00AM Wednesday 11:00AM Wednesday 12:00PM Wednesday 1:00PM Wednesday 2:00PM Thursday Thursday 8:00AM Thursday 9:00AM Thursday 10:00AM Thursday 11:00AM Thursday 12:00PM Thursday 1:00PM Thursday 2:00PM Friday Friday 8:00AM Friday 9:00AM Friday 10:00AM Friday 11:00AM Friday 12:00PM Friday 1:00PM Friday 2:00PM Other (please specify) OK THANK YOU!