Wellness Coaching Assessment Form

Wellness Coaching Assessment Form

Form fields marked with an asterisk (*) are required.
Ivy Tech Evansville students interested in wellness coaching can complete this form to get started. You’ll be contacted as soon as possible after submission.
Section 1: Contact Information
Preferred method of contact:
required

Section 2: Physical Wellness
Caring for your body through activity, nutrition, and sleep.

I get regular physical activity (150+ min/week).
required
I eat balanced, nutritious meals most days.
required
I get adequate sleep (7-9 hours/night).
required
Would you like help improving your physical wellness?
required
Readiness to change
required

Section 3: Emotional Wellness
Managing stress, emotions, and mental health support.

I manage stress effectively.
required
I have healthy coping strategies.
required
Would you like help with emotional wellness?
required
Readiness to change
required
Section 4: Financial Wellness
Budgeting, saving, and managing financial stress.
I maintain a monthly budget.
required
I feel in control of my finances.
required
Would you like help with financial wellness?
required
Readiness to change
required
Section 5: Occupational Wellness
Satisfaction with work, studies, or career direction.
I feel fulfilled by my work or studies.
required
I'm confident about my career path.
required
Would you like help with career or time management?
required
Readiness to change
required
Section 6: Intellectual Wellness
Pursuing learning, curiosity, and mental growth.
I regularly challenge myself intellectually.
required
I'm engaged in learning or creative pursuits.
required
Would you like help with study habits or motivation?
required
Readiness to change
required
Section 7: Social Wellness
Building connections and support networks.
I have positive relationships and support.
required
I feel comfortable asking for help.
required
Would you like help with social wellness?
required
Readiness to change
required
Section 8: Spiritual Wellness
Exploring meaning, values, mindfulness, or purpose
I feel connected to a sense of purpose.
required
I practice reflection or meditation.
required
Would you like help with spiritual wellness?
required
Readiness to change
required
Section 9: Environmental Wellness
Creating healthy, supportive environments and sustainable habits.
I feel safe and comfortable in my environment.
required
I regularly spend time in nature or make eco-conscious choices.
required
Would you like help improving your environment?
required
Readiness to change
required
Section 10: Creative Wellness
Expressing yourself through art, hobbies, or creative outlets.
I participate in creative activities that relax me.
required
I make time for hobbies or self-expression.
required
Would you like help exploring your creativity?
required
Readiness to change
required
Final Section: Goals & Coaching Interest
Would you like to schedule a 1-on-1 session with a Wellness Coach?
required