Name
Birthday
Address
Are you married? YesNoDivorced
Do you have any children? YesNo
Do you work? YesNo
If you work, how long have you been working?
If you work, what hours are you at work? Morning (7AM-12PM)Afternoon (12PM-5PM)Evening (5PM-8PM)Night (8PM – 11PM)Other
Who works in your family?
Can you speak, write and read English? AdvancedIntermediateBeginner
What is your native language?
Can you speak, write and read your native language? AdvancedIntermediateBeginner
What are your talents? (Cook, Dance, Art, other)
Which technology below can you use? PhoneComputerInternetIpad/tablet
What are you most thankful for?
If you could change or better something in your life, what would it be? (Example: health, emotions, spirituality, relationships)
What holds you back from being happy?
What do you need to reach your fullest potential?
Is there anything that you would like to share with RISE Programs that you have not shared already?