Registration.Please fill out this registration form for the A Healthier You Program. Name * First Name Last Name Email * Birth Year * Age * Gender * Male Woman Transgender Woman Transgender Male Non-conforming Not Listed Ethnicity * Asian Black/African American Caucasian Hispanic/Latinx Native American Pacific Islander Other Prefer not to answer Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Employment * Yes No Full Time Part Time Phone * (###) ### #### What is your intention for participating in AHY Program? * Do you own a yoga mat? * Yes No Are you intentional with your life, goals, and actions? * Yes No Do you know what affirmations are? * Yes No Do you use affirmations daily? * Yes No Do you journal often? * Yes No How often do you journal? * Everyday Once a week Every once in a while Never Do you attend therapy? * Yes No Do you have social support (family, friends, etc.)? * Yes No Can you identify your stressors? * Yes No How are you managing your stress? * Not so good Okay Good Very good Do you meditate? * Yes No Do you practice yoga? * Yes No Sometimes Do you practice breathing exercises? * Yes No Sometimes Reasons for not practicing yoga? * Cost Transportation Equipment Physical Condition Time Other How are you with saving your money? * Very good Good Not so good Need assistance Do you feel your budget needs more improvement? * Yes No Do you have good eating habits? * Not so good Okay Good Very good Do you exercise? * Yes No How likely are you to follow through on your goals? * Very likely Likely Not likely How often do you take time to reflect on your actions and habits? * Once a week Every once in a while Never Everyday What are your physical habits? * Are you satisfied with your physical habits? * Yes No What are your social habits? * Are you satisfied with your social habits? * Yes No What are your financial habits? * Are you satisfied with your financial habits? * Yes No What are your mental habits? * Are you satisfied with your mental habits? * Yes No What are your spiritual habits? * Are you satisfied with your spiritual habits? * Yes No What are your emotional habits? * Are you satisfied with your emotional habits? * Yes No What area of your life would you like to improve on? * How did you hear about us? * Social Media Newsletter Word of Mouth Online Other Thank you!
