TELL ME ABOUT YOURSELF
What time zone are you in?
{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
How did you hear about the Mind Body Rewire Program?
{"type":"checkbox","name":"foundMe","width":50,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Facebook \nWeb Search\nPodcast\nA friend/person\nYouTube\nInstagram\nNewsletter\nOther"}
If a person referred you, please type their name below
{"type":"text","name":"__generic2","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
Do you work at this time?
{"type":"checkbox","name":"__generic3","width":25,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Full time\nPart time\nRetired\nUnable"}
Your Age
{"type":"text","name":"age","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
What are your biggest struggles when trying to heal your symptoms?
{"type":"textarea","name":"struggles","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What symptoms/diagnosis are you seeking help for?
{"type":"textarea","name":"symptoms","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
How long have you had these symptoms?
{"type":"text","name":"__generic7","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
What kind of approaches have you tried to resolve these symptoms?
{"type":"textarea","name":"triedbefore","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
How does having these symptoms and not finding the solution make you feel?
{"type":"textarea","name":"feelings","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
If you could wave a magic wand when it comes to your health, what would your #1 desired outcome be in the next 6 months?
{"type":"text","name":"desiredoutcome","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
What do YOU believe is the root cause to your symptoms?
{"type":"textarea","name":"rootcause","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Have you ever worked with a coach or mentor before?
{"type":"text","name":"coachbefore","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
What percent do you believe you are responsible for your healing?
{"type":"text","name":"__generic13","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
On a scale of 0-10, how willing are you to be uncomfortable for the sake of your healing?
- 10 being that you know shifting old patterns can be uncomfortable but understand that its necessary to heal and are willing to do it.
- 1 meaning you don't want to be uncomfortable and you're not willing to make any changes to create the result that you want.
{"type":"text","name":"__generic14","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}
Are you willing to put your healing and the work that is required for your healing as a priority in your life? This means you will need to spend 30-60 minutes a day on your healing.
{"type":"checkbox","name":"__generic15","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}
Are you open to the idea that physical ailments have an emotional connection?
{"type":"checkbox","name":"__generic16","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}
What would be the length of time that you are willing to invest in your healing?
{"type":"checkbox","name":"__generic17","width":50,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"1 month\n3 months\n6 months\nWhatever it takes"}
What kind of solution are you looking for right now?
{"type":"checkbox","name":"__generic4","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"DIY Solution (money is tight & I'd rather learn and do it myself\nDone WITH me solution (do it myself with the guidance of a coach)"}
The MBR Program includes a variety of tools to assist with healing including, meditation, yoga, and hypnosis. Are you ok with using these?
{"type":"checkbox","name":"__generic5","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}
What do YOU think is the biggest block getting in the way of your healing?
{"type":"textarea","name":"biggestblock","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What are the biggest reasons you're drawn to working with a coach versus healing on your own?
{"type":"textarea","name":"drawntocoaching","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Are you on any medications? If yes, which ones?
{"type":"textarea","name":"medications","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Are you open to healing your symptoms without detoxing, diet restrictions or pills?
{"type":"checkbox","name":"__generic21","width":33,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo \nMaybe"}
Have you listened to Jenny's Podcast (Simplify Your Healing Podcast) and have a good idea of the type of work that Jenny and her team does?
{"type":"checkbox","name":"listenedtopodcast","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes\nNo"}
