Warm Welcome,
We first to thank you for taking the courage to reach out. We also want to take you for taking out the time for fill out this quick pre-qualification survey. All information will be kept strictly confidential. We look forward to see if we can be are your service.
Section 1: Background & Goals
On a scale of 1-100 how happy motivated are you with your life right now? What do you hold valuable in your life that brings you happiness?
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What are your sleep patterns like? Are you waking up groggy? Are you dreaming? When was the last time you woke up "fresh." How many hours do you get in on average? Are you going into REM sleep?
{"type":"textarea","name":"__generic2","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"Sleeping patterns are directly linked how much mental energy you will have next day."}
Briefly describe your current life situation and 3 key challenges you're facing, preventing you to be best version of yourself. (Be as clear as possible)
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What inspired you to seek support at this time in your life?
{"type":"text","name":"__generic4","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":"I’ve tired everything else and nothing seems to be working."}
Where did you hear about our amazing services. (Google, Facebook, Friend, Family - Please kindly provide full name of referral)
{"type":"text","name":"__generic5","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":"I’m not where I want to be."}
Section 2 : Goals & Aspirations
How do you want to grow and evolve as a person over the next year or five years? List 3 goals you like to reach. (Please crystal clear as possible, even if you are not sure, its okay that's why you are filling this out now)
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On a scale of 1 to 10, how sincerely committed are you to making drastic positive changes in your life right now? (1 = Not committed, 10 = Extremely committed)
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What wouldn't happen if you didn't achieve your goals and outcomes in the near future? How would that make you FEEL and how will it effect areas of your life? (Financially, Emotionally, Mentally, etc)
{"type":"textarea","name":"__generic8","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"Imagine if nothing changed what would the outcome be?"}
What is your biggest fear that prevents you from achieving your goals or living the life you desire?
{"type":"textarea","name":"__generic9","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"List all things that give you “anxiety.”"}
Section 3: Experience and Preferences
How do you typically cope with stress or challenges in your life? What are the 5 things your putting up with?
(List everything that has worked or hasn't worked ie. drugs, medication, therapy, working out, alcohol)
{"type":"textarea","name":"__generic10","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"Keep in mind all information will be kept strictly confidential!"}
Are you comfortable with virtual sessions (online) or do you prefer
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Section 4: Therapy, Medication, and Health
Are you currently seeing a therapist or counselor?
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Are you currently taking any medication that we should be aware of? If yes, please provide details?
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Do you have any pre-existing health conditions or concerns that we should be aware of before proceeding with coaching or hypnosis? If yes, please provide details:
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Section 6: Availability and Investment
What is your preferred frequency of sessions? (Select one)
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What is your budget for personal transformation?
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Our professional development program is a serious long term investment. We kindly ask only to submit this survey if you’re 100% willing to commit the time, effort, into self care and personal inner growth (Yes/No)
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Thank you for taking the time to complete this pre-qualification survey. We appreciate your honesty and look forward to potentially working together to help you achieve your desired outcomes. We discuss the best program for you in our pre-qualification interview.
