Name
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First Name
Last Name
Email
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Today's Date
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MM
DD
YYYY
Date of Birth
*
MM
DD
YYYY
How often do you check your email?
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Where are you based?
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How did you hear about me?
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What challenges are you currently facing and what are you needing support with? (Please include anything related to physical health, spiritual health, mental health, emotional health, mental blockages, limiting beliefs, etc.)
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What are you looking to achieve? What are your health & life goals?
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Have you had any major surgeries?
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Yes
No
If you answered yes to the question above, please explain below:
Have you ever been treated for mental illness?
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Yes
No
If you answered yes to the question above, please explain below:
Are you interested in a holistic coaching approach that targets the mind, the body, and the spirit?
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Are you familiar with Human Design?
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Human Design can provide tremendous insight into your spiritual and energetic body, is this something you'd be open to exploring further during the program?
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How committed are you to making the necessary changes to reach your goals?
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Why are you ready to make this change now?
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Are you currently in a position to financially invest in yourself?
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How much is your health and wellbeing worth to you?
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If accepted, are you ready to start immediately?
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