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Name

Business Name (If Applicable)

Mobile Number

What are your top 3 challenges that you feel are holding you back in your life or business?

Why is NOW the time to solve this problem?

If you knew there were NO obstacles, what 3 goals would you like to see happen in the next 12 months?

Which areas are you most interested in working on? Check all that apply.

Life

Business

Health

Relationships/Family

Work

How did you hear about me?

Why do you want to work with me?

Are you willing to invest in yourself to learn how to build the life and/or business you love?

If the return on investment makes sense, I’ll do whatever it takes.

I’d be a little intimidated, but because I’m committed to doing it, I will do it with the right guidance and support.

Other (Comment Below)

Right now I…

Have the financial resources to invest in my personal growth and life/business goals.

Have access to the financial resources to invest in my personal growth and life/business goals.

Don't quite have the financial resources, and investing at this time would cause financial distress.

Time's up