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Client Intake Form
Name
*
First
Last
Email
*
Cell Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Which Category Includes Your Age?
*
18-19
20-29
30-39
40-49
50-59
60-69
70-79
80 or older
Which Category Best Describes your Racial Background? (Select all that apply)
*
American Indian/Indigenous American and Alaska Native alone
Asian alone
Black or African American alone
Hispanic or Latino alone
Middle Eastern alone
Native Hawaiian and Other Pacific Islander alone
White alone, not Hispanic or Latino
Two or More Races
Prefer not to disclose
What is Your Gender?
*
Agender
Female
Gender Fluid
Male
Non Binary
Prefer not to disclose
What is Your Sexual Orientation?
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Asexual
Bisexual
Gay
Heterosexual
Lesbian
Pansexual
Prefer not to disclose
Which Category Includes Your Income?
*
0 - 9,999
10,000 - 14,999
15,000 - 19,999
20,000 - 24,999
25,000 - 29,999
30,000 - 34,999
35,000 - 39,999
40,000 - 44,999
45,000 - 49,999
50,000-54,999
55,000 - 59,999
60,000 - 64,999
65,000 - 69,999
70,000 - Greater than 70,000
Organization
*
Organization Field
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Non Profit
Clergy
Title at Organization
*
1st Role
*
Executive Leadership
Program Management
Direct Service Provider
Administrative
N/A
2nd Role
Executive Leadership
Program Management
Direct Service Provider
Administrative
N/A
3rd Role
Executive Leadership
Program Management
Direct Service Provider
Administrative
N/A
4th Role
Executive Leadership
Program Management
Direct Service Provider
Administrative
N/A
How many years have you been with this organization?
*
How satisfied are you at your current organization and in your current role?
*
I am extremely dissatisfied
I am very dissatisfied
I am dissatisfied
Neutral
I am satisfied
I am very satisfied
I am extremely satisfied
What are the reasons you didn’t give yourself a higher score for how satisfied you are in your current role? (Select all that apply)
*
Underpaid
Burn Out
Stress
Unfilled
Career goals outside of nonprofit sector
Lack of sustainability
Unrealistic expectations from organization
Unrealistic expectations from self
Unresolved conflict
Ill-equipped (in training or skill level)
In-effective leadership
Lack of support from organization
Overworked and understaffed
Life transition (moving, child, etc.)
Lack of upward mobility within organization
Other
If you were to leave your current job, what would be the reason for you leaving your nonprofit organization? (Select all that apply)
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Underpaid
Burn Out
Stress
Unfilled
Career goals outside of nonprofit sector
Lack of sustainability
Unrealistic expectations from organization
Unrealistic expectations from self
Unresolved conflict
Ill-equipped (in training or skill level)
In-effective leadership
Lack of support from organization
Overworked and understaffed
Life transition (moving, child, etc.)
Lack of upward mobility within organization
Other
How long have you worked within the nonprofit sector?
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1-2 year(s)
3-5 years
6-8 years
9-11 years
12+ years
How long do you plan to work within the nonprofit sector (total)?
*
1-2 year(s)
3-5 years
5-10 years
10-20 years
20-30 years
30 or more years
In the past, have you received the following services? (Select all that apply)
*
Spiritual Direction
Counseling
Nutrition Coaching
Personal Training
Life Coaching
Gym Membership
None of the above
Currently, are you receiving any of the following services? (Select all that apply)
*
Spiritual Direction
Counseling
Nutrition Coaching
Personal Training
Life Coaching
Gym Membership
None of the above
If you do receive the above services, how often do you receive them?
*
I understand what self-care is.
*
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
In what ways do you feel like you’re currently practicing self-care?
*
What is preventing you from practicing self-care? (Select all that apply)
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Lack of time
Lack of money
Don’t know how
Don’t know what self-care looks like for me
Lack of support from organization
Unsure of how to start
Don’t know who to connect with for help
Other
Nothing is preventing me
If you were given a magic wand, what are all the ways you would be practicing self-care if there were no barriers to it?
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Please list the top 3 things that are currently stressing you the most:
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Have you taken any personality assessment tools (Enneagram, Myers-Briggs, DISC, StrengthFinders, etc)? If yes, please list your types and/or strengths below if you know them:
I understand that enrolling in a self-care plan with Day 7 will require time, effort and energy on my part. I will respond to emails and communicate effectively and timely regarding my plan. I am willing to take the time to invest in myself and my own self-care.
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I agree
I am not able to commit to this at this time, but would like to stay on the list for the future.