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Name*
Last name*
Email*
Primary Motivations*
Multiple choice*
25-35
36-45
46-55
65+
Option 5
Online Assessment
Get in touch
Name*
Last name*
Email*
Current Life Phase select all that apply*
Multiple choice*
Advancing in Carrer
Work and Life Balance
Planning Major Life Transition
New Parent and Young Children
Empty Nest Transition
Preparing for Retirement
Recent Health Concerns
Online Assessment
Get in touch
Name*
Last name*
Email*
Primary Wellness Goal Select Top 2*
Multiple choice
Reduce Stress and Improve Mental Clarity
Improve Physical Fitness and Energy
Develop Better Nutrition and Habits
Create financial Wellness Plan
Integrate Overall Life Balance
Navigate Overall Life Transitions Sucessfully
Section 2 Current Wellness state (45 seconds) Assess Current Pain Points and readiness for change. Rate your current Stress Level (1-10 scale with descriptors)
1-3 generally calm and manageable
4-6 Moderate stress some challenging days
7-8 High stress effecting daily life
9-10 overwhelming stress, Impacting health and relationships
Online Assessment
Get in touch
Name*
Last name*
Email*
Energy and Physical Health How Would you Rate your current Energy Levels ?*
Multiple choice
Excellent -I feel energized most days
Good -generally energetic with casual dips
Fair- energy varies significantly day to day
Poor- often tired struggle to maintain energy
Work -Life Integration. which of the following best describes your situation*
I maintain clear Boundaries and feel balanced
I generally manage well but sometimes struggle
work often spills into personal time
I feel constantly overwhelmed trying to manage everything
Online Assessment
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Name*
Last name*
Email*
MessageHealth and Nutritional Habits . How consistent are your healthy eating and exercise habits*
Multiple choice*
Very consistent- Maintain 1 Healthy Routine
Somewhat consistent-good Habits but Irregular
Inconsistent- I know what do to but struggle to maintain
Minimal- I want to improve but don't know where to start
Multiple choice
Lack of Time
Inconsistent motivation
Information overload. I don't know where to start
competing priorities
lack of accountability
Financial Constraints
Physical Limitations or Health Concerns
Family or Work Demands
previous wellness experience*
have worked with wellness Professional before
No this would be my first experience
Yes with some success but looking for a more comprehensive approach
Yes, but previous approaches did not work with my lifestyle
Yes I've had success but need ongoing support
Preferred service Delivery 9 select all that apply*
Virtual Online Consultations
Intensive short-term programs
Ongoing Monthly Support
Multiple choice*
Critical- I need Integrated Financial and Health Planning
Important- would like some financial wellness guidance
Moderate-Open to financial tips as part of overall wellness
Low priority primarily focused on Health and Lifestyle
Multiple choice*
under 150 /month
150-300/ month
300-500 / month
500 + /Month
Multiple choice*
Immediately
Within the Next Month
within 2 - 3 months
still exploring options
depends on right fit
communication Preferences. How would you like to receive your Personalized wellness road map ?*
Email Report
Scheduled Phone Consultation
Live discussion Instant Messaging
Online Assessment
CONTACT US
constantine@well-balance-life.com
(702)
9808991
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