Name
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First Name
Last Name
Email
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Phone
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
On a scale of 1-10, how confident do you feel in yourself right now?
What is the biggest fear holding you back in life right now?
Do you feel like you’re living with a sense of purpose?
Yes, I feel deeply aligned with my purpose.
Somewhat, I have an idea but lack clarity.
No, I feel lost and unsure of what I want.
On a scale of 1-10, how would you rate your overall physical health? (1 = Weak and struggling, 10 = Strong, fit, and full of energy)
Do you experience any of the following? (Check all that apply)
What does your current fitness routine look like?
What’s one thing you know you need to change about your health?
What emotion do you struggle with the most? Why?
On a scale of 1-10, how well do you understand and manage your emotions? (1 = I avoid them, 10 = I handle them masterfully)
When life gets hard/stressful/overwhelming, what is your default coping mechanism?
How often do you express your emotions in a healthy way? (1 = Never, 10 = Daily)
On a scale of 1-10, how stressed do you feel on a daily basis? (1 = Never stressed, 10 = Overwhelmed constantly)
What are your top 3 sources of stress?
How do you currently manage stress? (Check all that apply)
How much energy do you have throughout the day?
I feel tired all the time.
My energy crashes midday.
My energy is decent, but inconsistent.
I feel consistently strong and energetic.
On a scale of 1-10, how organized do you feel in life? (1 = Life feels chaotic, 10 = I feel structured and in control)
Tell me about your daily routines & rituals if you have any?
What’s your biggest challenge with time management or staying on track?
On a scale of 1-10, how consistent are you? (1-never have the same day twice, 10-consistency is my middle name)
On a scale of 1-10, how comfortable do you feel in social situations? (1 = I avoid them, 10 = I thrive in them)
When interacting with women, what describes you best?
I feel confident and natural.
I overthink and struggle to be myself.
I avoid interactions because of fear or insecurity.
What is one challenge you face in relationships or dating?
What 3 things bring you the most joy in life?
On a scale of 1-10, how happy and fulfilled do you feel in life right now? (1 = Miserable, 10 = Deeply fulfilled and thriving)
On a scale of 1-10, how satisfied are you with your financial situation? (1 = Stressed and struggling, 10 = In full control and thriving)
What do you do for work, and do you feel aligned with it?
What’s your biggest goal when it comes to money, career, or business?
If you had complete confidence and no fear, what would your life look like in 6-12 months?
Why is this goal important to you?
How will you feel once you've achieved this goal?
What’s the #1 thing getting in the way or stopping you from getting there?
Are you 100% ready to commit to your growth and transformation?
Yes, 100%, I’m all in.
I want to be, but I have doubts.
No, I’m not ready yet.
