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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 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?*
- 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*
- 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)*
- 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?*
- 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)*
- 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?*
Please list the top 3 things that are currently stressing you the most:*
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.*
- I agree
- I am not able to commit to this at this time, but would like to stay on the list for the future.