LEGACY GROUP WEEKLY WELLNESS FEEDBACK

NAME

How would you rate the presence of the following feelings or experience over the last 7 days, where 1 is nonexistent and 5 is very much and all the time. All fields are optional.

STRESS

1 2 3 4 5

GENERAL EFFICACY ⓘ

1 2 3 4 5

POSITIVE THOUGHTS ABOUT MYSELF

1 2 3 4 5

SENSE OF PURPOSEFULNESS

1 2 3 4 5

ENERGY LEVELS

1 2 3 4 5

GROWTH/STRETCHING

1 2 3 4 5

FEELING CONNECTED

1 2 3 4 5

FAMILY ROLE EFFICACY ⓘ

1 2 3 4 5

PHYSICAL HEALTH

1 2 3 4 5

BUSY-NESS

1 2 3 4 5

PREDOMINANT EMOTION

Happy Playful Curious Thankful Couragious Focused Proud Loved Hopeful Excited Bored Angry Frustrated Stressed Jittery Afraid Sad Depressed Moody Shame Drained

WHO ARE YOU CONNECTING WITH THE MOST?

WHO WOULD YOU MOST LIKE TO CONNECT WITH MORE?

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