First Name *

Last Name *

Email *

Phone *

Date of birth *

Country *

City *

Relationship Status *

How Many Kids?

Have you ever worked with a coach or mentor before? (Yes/No)

Yes

What do you do for work? *

How many years at your current profession? *

Your website URL (If you have a business)

Team size (If you have a business)

How many hours p/week do you work?

How Effective/Productive Are You While Working?

What are some of the ways you disconnect/recharge?

What do you do for fun?

Energy level on average?

Clarity level (I have a clear vision of my next 3-12 months)

What is your overall health/fitness level?

Focus Level (How would you rate your focus)

Overwhelm Level (Stress, overwhelm, frustration)

How satisfied in your business/job ?

How satisfied are you with your romantic relationships?

How satisfied are you with your social relationships? (Friends & family)

Overall life satisfaction level?

Briefly describe what you do... Give me a general sense of what you are up too... Be Specific about your business, job, industry...And if you're working on multiple projects, let me know

What major stressors or challenges are you struggling with right now?

What distracts you the most from being more productive?

What’s your vision for where you want to be in the next 24-36 months?

Why must you achieve this vision no matter what?

What Is Your Number ONE Goal In The Next 12 Months

Picture Yourself 3 months from now thinking "Wow, I can't believe I Got that done"... What did you accomplish? *

What Is Your Quantum Leap You Need To Make? (What's that one thing you know you should be doing now that will give you 10x results - but are afraid, procrastinating, or making excuses on? )

Anything else I should know about you?