Wellness Reflection

Center for Counseling, Healing & Growth

Reunion

Please rate your EATING *

Please rate your EXERCISE *

Please rate your SLEEP *

Overall, how are you doing? *

Great

I am doing all right

I could use more support

How do you rate your relationships & social activities? *

In the past 7 days, rate your level of ADDICTION *

In the past 7 days, rate your level of DEPRESSION *

Please rate your ENERGY *

Is there anything specific you want to address today?

Wellness Reflection

Please submit this assessment prior to your appointment.

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How can we help?

In the past 7 days, rate your level of ANXIETY *

To what extent are you able to carry out your everyday activities? *

How would you rate your quality of life? *

Name: *

How would you rate your overall health? *

Please rate your ORDER in Work & Home *