| Personal Details |
| Name: |
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| Address: |
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| Home Phone: |
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| Work Phone: |
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| Email: |
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| Your current occupation: |
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| Partner’s Name: |
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| Your Birth date and/or age: |
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| Your Past/Present History, Interests and Goals
(Please check the things you want to improve in your life, have tried to improve in your life or have actually improved in your life.) |
| Gain Self-esteem
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| Gain confidence
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| Change my work/career
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| Improve my relationships
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| Create greater health/wellness
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| Increase my motivation
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| Have more money
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| Get Paid More
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| Get Out of Debt
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| Decrease feeling stressed
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| Feel more relaxed
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| Lose or gain weight
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| Get my body in shape and be fit
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| Have the time to do things I want to do
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| Get more done in les time
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| Create more success in my life
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| Want to own a business but need a job
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| Do You Currently Have A Coach? |
| YesNo |
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| Have You Ever Worked With A Coach? |
| YesNo |
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| Vision and Goals (Please check all that apply to you)
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| I Want Greater Career Satisfaction
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| I Want Better Life/Work Balance
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| I Want to Reduce Stress
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| I Want Greater Health/Wellness
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| I Want to Lose or Gain Weight
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| I Want To Create More Time
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| I Want To Procrastinate Less
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| I Want to be Less Fearful
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| I Want to do Things With More Ease & less effort
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| I Want To Live My Life Purpose/Mission
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| I Want To be Fit
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| I Want More Energy
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| I Want to Think More Positively
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| I Want Better Relationships
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| I Want More Energy
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| I want greater Self Esteem
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| I Want More Confidence
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| I Want To Bring in More Money
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| Current Reality |
| Do You Have A Life Partner? |
| YesNo |
| Are you at the weight you want to be? |
| YesNo |
| Do you have the employment you want? |
| YesNo |
| Are you doing the activities you want? |
| YesNo |
| Do you have the relationships you want? |
| YesNo |
| Do you have the money you want? |
| YesNo |
| Are you in a relationship that nurtures you? |
| YesNo |
| Do you have children? |
| YesNo |
| Are you spiritually where you want to be? |
| YesNo |
| Are you growing and learning at a pace you enjoy? |
| YesNo |
| Are you comfortable with your community? |
| YesNo |
| Do you have the health and wellness you want? |
| YesNo |
| Do you have hobbies and interests you enjoy and plenty of time for them? |
| YesNo |
| Do you have the family relationships you desire? |
| YesNo |
| Do you have fulfilling friendships? |
| YesNo |
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| Pattern Breaker |
| Do you work too much? |
| YesNo |
| Do you work at a job you don’t like? |
| YesNo |
| Do you have the money you want/need? |
| YesNo |
| Are you missing key relationships? |
| YesNo |
| Do you feel stressed/worried? |
| YesNo |
| Are you focused? |
| YesNo |
| Are you missing balance? |
| YesNo |
| Do you have time for hobbies? |
| YesNo |
| Are you focused on problems/challenges? |
| YesNo |
| Are you a procrastinator? |
| YesNo |
| Does it seem you never get what you want? |
| YesNo |
| Are you living your life purpose/mission? |
| YesNo |
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| Six Month Goals |
| Career satisfaction
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| Create more time
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| Better relationships
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| Life/work balance
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| Procrastinate less
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| More energy
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| Reduce stress
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| Less fearful
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| Self esteem
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| Health/wellness
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| Do things with more ease/effortlessness
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| Confidence
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| Lose weight
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| Live life mission
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| Bring in more money
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| Other |
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Please enter your name and email address below so that we can send you a copy of your assessment |
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Your Name:
Your Email: |