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Important Note: 

When you click 'Submit' you must confirm your answer by clicking 'Done' 
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Full Name:*

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Telephone or skype name you would like to be contacted on?

Best time to contact and your time zone:

Best time to contact and your time zone:

List Your Top 3 Goals in Order of Priority:

List Your Top 3 Goals in Order of Priority:

Goal # 1.
Goal # 2.
Goal # 3.
Level of Commitment

Level of Commitment

On a scale of 1 to 10, how committed are you to achieving each goal? (1 = not important, 10 = it has to happen) For Example: Goal #1. 10/10 Goal #2. 9/10 Goal #3. 9/10
How can we help?

How can we help?

How do you feel that coaching or the beliefs reconditioning process can best serve you? What we mean is this, what are you hoping to gain by working with us? What are you looking for in a coach? What would you get the most value from through a coaching relationship? (For example: Accountability)