Integrated Life Optimization Activation Form
Share your goals, routines, ratings, constraints, and mental-health screening responses to help tailor a non-medical 12-week wellness plan.
Program Identification and Focus
Client ID
*
Primary Life Area to Improve
*
Please Select
Physical Health
Mental Wellbeing
Nutrition
Sleep
Stress Management
Fitness
Work-Life Balance
Relationships
Productivity
Other
Desired 12-Week Outcome
*
Current Life Baseline Ratings
Life satisfaction
Very low
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very low, 10 is Excellent
Daily manageability
Very difficult
1
2
3
4
5
6
7
8
9
Very manageable
10
1 is Very difficult, 10 is Very manageable
Stress
Very low
1
2
3
4
5
6
7
8
9
Very high
10
1 is Very low, 10 is Very high
Energy
Very low
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very low, 10 is Excellent
Sleep quality
Very poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very poor, 10 is Excellent
Purpose and direction
Very unclear
1
2
3
4
5
6
7
8
9
Very clear
10
1 is Very unclear, 10 is Very clear
Social support
Very low
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very low, 10 is Excellent
Work-life balance
Very poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very poor, 10 is Excellent
Routine, Capacity, and Constraints
Morning routine days per week
Evening routine days per week
Estimated overcommitted hours
Biggest time and energy drains
Habits already working
Habits attempted but not sustained
Friction points
Time available each day (hours)
Upcoming constraints
Preferred anchor behavior
Please Select
Morning movement
Hydration
Planning review
Evening wind-down
Consistent sleep time
Other
Accountability and readiness
Preferred accountability style
Text check-ins
Scheduled calls
Email reminders
App notifications
Partner/accountability buddy
Other
Readiness
Not ready
1
2
3
4
5
6
7
8
9
Fully ready
10
1 is Not ready, 10 is Fully ready
Confidence
Not confident
1
2
3
4
5
6
7
8
9
Very confident
10
1 is Not confident, 10 is Very confident
Preferred contact style
Please Select
Text message
Email
Phone call
App notification
Other
Safety screening
If you are experiencing suicidal thoughts, feel unable to function, have severe anxiety or depression, or have new or worsening medical symptoms, stop here and seek immediate help from a qualified professional or emergency services. This program is non-medical and does not replace care from a clinician.
Mental health context
Over the last 2 weeks, how often have you felt nervous, anxious, or on edge?
Not at all
Several days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you not been able to stop or control worrying?
Not at all
Several days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you had little interest or pleasure in doing things?
Not at all
Several days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you felt down, depressed, or hopeless?
Not at all
Several days
More than half the days
Nearly every day
Urgent concern or need immediate support?
No
Yes
Medical or physical limitations
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