Name
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First Name
Last Name
Phone
*
(###)
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####
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
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MM
DD
YYYY
Do you have children? How old are they?
Please rate yourself in the following areas of your life on the scale.
Clarity: Do you feel you are clear about who you are, your purpose and the direction you want to go in life
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Energy: Do you consistently have enough mental and physical energy needed to excel, accomplish your goals, and feel motivated and happy?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Courage: Do you take action and consistently express who you truly are and what you truly are and what you truly think, need, and desire the world?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Productivity: Are you consistently focused and effective, and are you good at minimizing distractions and maintaining priorities?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Influence: Do you feel you have the social influence with your family, friends, and team needed to accomplish your goals?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
What do you do for a living, and why did you choose that career?
What are your top 3 goals you are striving to achieve right now?
What major stressors or challenges are you struggling with right now?
When you feel like your most successful and happy self, what makes you feel that way?
What would your dream life look like if you could wave a wand and make it happen?
What else has prevented you from having that dream life?
What goal or dream have you ever given up on or failed at, and what do you believe caused you to stop or fail?
What are you most proud of and excited about in your life?
What negative recurring thoughts, fears, or behaviors would you like to overcome in order to feel more psychologically free, confident and successful
What eating, exercise or general health habits would you like to begin or break in order to feel stronger and more healthy physiologically?
What distracts you the most from being more productive, and what major projects or missions are you struggling to complete faster or more efficiently?
If you were more persuasive or influential, what dream or desire would you ask others to support you in achieving?
When do you struggle to be fully present in your day or in any of your relationships?
How purposeful do you feel in living each day, and how would you describe your purpose?
Why would you like to work with a high performance coach?
Why do you feel you could be a great student or coaching client if we worked together?
How willing are you to invest the energy, finances, and time into the work we would do together in your business and for you to create the clarity & results you are seeking and deserve?
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Are you ready to invest in your business?
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Yes I am ready to put down a deposit
Yes I am ready to invest in myself and my business
Yes I am ready to invest and I have questions
I don’t have the funds ready to invest at this time