Corporate Wellness Survey Step 1 of 2 50% Thank you!We appreciate you taking a few moments to complete this survey so that we may best serve your company's needs. Because every company is different, we will take the information you provide us with and create a comprehensive plan or proposal based on your desires. Your Name* First Last Name of Company* Method of Contact (Check all that apply) Telephone Email Fax PhoneFaxEmail* Company Website Number of Employees*1-1011-3031-7576-100101 - 250251 - 1,0001001 - 10,00010,000 +Address of Company Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Your Position with the Company* How did you hear about DREAM Wellness?* What Services are you Interested In?Please use this portion of the form to let us know which of the following services you would like to potentially have offered to your company's employeesWellness Assessment / Digital Nerve Scan (takes 10 minutes)* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location for Wellness Assessments* On-site At a DREAM Wellness Location It Depends Body Fat Composition (takes 10 minutes)* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location Body Composition Scan* On-site At a DREAM Wellness Location It Depends Executive Business Coaching* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location for Executive Business Coaching* On-site At a DREAM Wellness Location Over the Telephone It Depends Individual Coaching for Employees* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location for Coaching* On-site At a DREAM Wellness Location Over the Telephone It Depends Team Building / Relationship Optimization* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location for Team Building* On-site At a DREAM Wellness Location It Depends Advanced Human Assessment and Results Review for Team Members* Very Interested Mildly Interested Maybe, but need more information Not Interested Human Assessments for Hiring* Very Interested Mildly Interested Maybe, but need more information Not Interested Nutrition and Weight Management* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location for Nutrition* On-site At a DREAM Wellness Location It Depends Chiropractic Care* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location for Chiropractic* On-site At a DREAM Wellness Location It Depends Chair Massage (on-site)* Very Interested Mildly Interested Maybe, but need more information Not Interested Full Body Table Massage* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location for Table Massage* On-site At a DREAM Wellness Location It Depends Acupuncture* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location for Acupuncture* On-site At a DREAM Wellness Location It Depends Personal Training* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location for Personal Training* On-site At a DREAM Wellness Location It Depends Group Fitness Classes (Yoga, Pilates, Barr, etc...)* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location for Group Fitness* On-site At a DREAM Wellness Location It Depends Group Meditation Classes* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location for Group Meditation* On-site At a DREAM Wellness Location It Depends Healthy Cooking Classes* Very Interested Mildly Interested Maybe, but need more information Not Interested Preferred Location for Healthy Cooking Classes* On-site At a DREAM Wellness Location It Depends Ergonomic Makeover* Very Interested Mildly Interested Maybe, but need more information Not Interested What other services (not listed above) would you like offered to your company and where would you like them offered?Seminars (Lunch and Learns, Half-day, Full-Day, Retreats)* Very Interested Mildly Interested Maybe, but need more information Not Interested Workshops, Seminars & RetreatsThis is a list of workshops that DREAM Wellness currently offers. Please check any of the workshops that you think would benefit your company / employees. Please note that while we have more than 100 options, if you let us know a topic of interest that is not listed, we can undoubtedly present something that will fill your needs!Workshops Offered Through DREAM Wellness* Living the DREAM (The 5 Facets of the Wellness lifestyle) Peak Performance Stress Management Back Safety and Injury Prevention: Secrets to a Healthy Spine 21 Day Purification Program (Detox/Cleansing) Raising Healthy Children: Naturally Stay Fit While You Sit Sit Right for Your Type 5 Secrets to Dealing with or Preventing Type II Diabetes Overcoming Fibromyalgia Improve Your Golf Game and Play Safely Headaches: A Real Pain in the Neck Finding the Fountain of Youth: Slowing the Aging Process The 10 Keys to Longevity Aging Gracefully Boosting Your Immunity The Chemistry of Life Spinal Health for Parents and Children Staying Focused on Life Straighten Up America Build Wisely: Creating a Foundation for Health, Wealth and Success Eat Smart 8 Simple Ways to Improve Sleep The Art of Meditation Backpack Safety Ergonomics 101 Self Centering / Power Centering Vaccination Facts and Myths Creating a Wow Customer Experience 25 Secrets of Extreme Profitability Irresistible Attraction 25 Secrets of Having the Life You Really Want Client Typing: Recognize Your 7 Specific Client Types Empowering People Relating to Co-workers, Clients or Customers Life Planning Personal Path: 12 Benchmarks to an Extraordinary Life Creating Financial Independence Organizational Development Listening: Hear What the Client is Saying Second Choice Business Building Attracting Ideal Clients Planning Your Time Creating and Clarifying Your Mission, Vision, Purpose and Philosophy Statements Marketing for Today and the Future Building Client Relationships for a Lifetime Hiring Your Ideal Assistant or Team Member How to Tell People What You Do and Engage Them in 15 Seconds Keys to Building Self-Esteem in Your Kids Designing the Ultimate Outcome for Your Client Introduction to Personal Coaching Introduction to Business Coaching Choosing Your Target Customer and the Cycle of Care Operate Your Business and Your Life from Your Values The Needless Program: Get Your Needs Met Goal Setting: How to Set Goals and Actually Achieve Them The Cycle of Life Alchemical Incompatibility: The #1 Killer of Relationships in Business, Home and Life Understanding How You Learn & Process Information Understanding How Others Learn & Process Information in Business, Home and Life How YOU Perceive Life Δ
