Your full name
Your email address
Your phone number with area code
*What kind of work do you do? (short answer text)
*Which of the following are you currently experiencing(check all that apply)
circles Feeling constantly on edge
Difficulty unwinding after work
Trouble sleeping or irregular sleep
Low or inconsistent energy
Saying yes when you're already at capacity
Feeling emotionally drained
Other ____________
*What does your typical work schedule look like?(shifts, hours, rotation, etc) (short answer text)
When do you feel your stress the most?(before work, during shifts, after work, days off, etc) (short answer text)
What happens when stress builds up for you (short answer text)
What have you already tried to manage your stress or burnout? (short answer text)
How easy is it for you to set and hold boundaries right now?(scale very difficult - very strong)
1-10
On your days off, do you feel truly rested? Why or why not(short answer)
Which area feels the most out of sync right now?
(circles) Sleep
Movement
Nutrition
Stress Regulation
Boundaries
Consistency
If things were working well for you, how would you want to feel day to day? (Long answer text)
What would being "steady" look like in your life or work? (Long answer text)
Why are you looking for support right now? (Long answer text)
Are you willing to commit time each week to implement what you learn?
Yes
Somewhat
Not sure
If this feels like the right fit, are you open to investing in support to create lasting change?
Yes
I'd like more information
Not at this time
Is there anything else you'd like me to know about your current situation?(Long answer text)