Self-Assessment Form Name * First Name Last Name Email * Phone Number * (###) ### #### What is your current profession and type of work? * What is your company’s website? What is your LinkedIn profile? Share the link What other types of projects and work have you done in the past (if not already listed on Linked In)? Who referred you? Did someone personally refer or introduce you to this program? Please type their name What do you want to contribute or create in the world? * What are your top 3-5 values? * What 2-3 things are you most excited about in your life right now? * What do you want more of in your life? What do you want less of in your life? * What else should we know about you? Health and cognitive performance * Please rate your current life in the following areas on a scale of 1 to 5 (1 = low; 5 = high): 1 2 3 4 5 Concentration and focus * Please rate your current life in the following areas on a scale of 1 to 5 (1 = low; 5 = high): 1 2 3 4 5 Creativity * Please rate your current life in the following areas on a scale of 1 to 5 (1 = low; 5 = high): 1 2 3 4 5 Love and connection * Please rate your current life in the following areas on a scale of 1 to 5 (1 = low; 5 = high): 1 2 3 4 5 Realizing full potential * Please rate your current life in the following areas on a scale of 1 to 5 (1 = low; 5 = high): 1 2 3 4 5 Family and community * Please rate your current life in the following areas on a scale of 1 to 5 (1 = low; 5 = high): 1 2 3 4 5 Spiritual development * Please rate your current life in the following areas on a scale of 1 to 5 (1 = low; 5 = high): 1 2 3 4 5 Self-confidence * Please rate your current life in the following areas on a scale of 1 to 5 (1 = low; 5 = high): 1 2 3 4 5 Emotional resilience * Please rate your current life in the following areas on a scale of 1 to 5 (1 = low; 5 = high): 1 2 3 4 5 Sense of safety and calm * Please rate your current life in the following areas on a scale of 1 to 5 (1 = low; 5 = high): 1 2 3 4 5 Being present * Please rate your current life in the following areas on a scale of 1 to 5 (1 = low; 5 = high): 1 2 3 4 5 What are the greatest challenges that you’ve had to overcome to date? * Type your name to certify this form * I attest that I have completed this form accurately and completely, and waive any rights to claims in the case of inaccurate or incomplete information. First Name Last Name Date * MM DD YYYY Thank you! Dr. Amy and Dr. Drew will follow up with you if your application is accepted to explain the next steps. Dr. Amy and Dr. Drew will follow up with you if your application is accepted to explain the next steps.
