Your Personal Wellness Microjourney

CONTACT INFORMATION

First Name

Last Name

What is Your Title?

Email *

What is your cell number?

We will be emailing you your results today, but can we add you to the TraumaWise mailing list?

Yes

No

Can we text your results to you in the future?

Yes

No

Have you previously completed this form?

What Event – or – Who referred you?

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Which of the following best describes how you felt coming into today’s experience

How are you feeling right now? (0 = terrible, 100 = amazing)

What does your current self-care routine look like right now?

How satisfied are you with your routine?

Please rate this statement: I believe that self-care is important, but I need more support and tools to develop a routine.

What is your favorite go-to coping strategy? (Hey, we don’t judge)

What coping strategy would you like to try?

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What is your greatest barrier to self-care? *

What strategies for overcoming barriers have been helpful in the past? *

What word or phrase helps to remind you of your strategies? (ex. “You Can Do Hard Things”) *

Great Job!

Now, you can take a moment to PAUSE until the end of the session and then we’ll come back to make your Personal Plan!

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It’s time to build your Personal Support Plan for your Wellness Microjourney!

First, you will select an area to focus on for the next 5 days. Then, you’ll set up a very simple plan for trying out a new practice in this area.

Remember – this is not a “have to” – this is to help you take one step forward.

To Which Area Would You Like to Pay Attention This Week?

What would you like to change for the better in this area for the next 5 days? *

How many times will you engage in the practice?

What wellness practice will you try for the next 5 days?

How much time will you give to each practice session?

What would be the best outcome after 5 days?

Who can you reach out to for support in this process? *

Which Affirmations most resonate with you? (pick up to 3)

Which words best describe how you feel after this experience?

Any questions we could answer?

By signing this, you are simply telling yourself that you are worth the effort to try something this week

AND

no matter if you succeed or not, you are still an awesome human on your journey to become a #healthyhuman

Signature

How likely are you to recommend this app to a friend or colleague?

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Your Personal Wellness Microjourney

In just 10 minutes, you will receive a personalized Wellness Microjourney in your email inbox!

CONTACT INFORMATION

TODAY’S SNAPSHOT

YOUR CURRENT CHALLENGES

YOUR PERSONAL SUPPORT PLAN

Remember – this is not a “have to” – this is to help you take one step forward.