First Name
    Last name

    Your age: 12 – 1717-2122-2930-3940-4950-5960 – 6465 or older



    Marital Status :SingleDivorcedMarriedSeparatedWidowed

    Spouse’s name & age:
    # Years married:

    Name (s) & age (s) of your children:

    Your occupation:

    Employed By:

    In what category would you place your current job/profession?
    Professional Executive/Managerial Office Asst./Clerical
    Govt. or military Entrepreneur Self-employed
    Teacher/Professor Homemaker Sales
    Retired Artist/Craftsperson Student


    What vocation would you do if you could do anything?

    If this is not your current role, what is preventing you achieving this?

    What 3 specific things do you want to learn, change or reinforce on this program?

    How would you know if you achieved them?

    Please describe your most successful achievements to date:

    Highest level of education completed?
    Less than High School High School University or TAFE
    trade Post Graduate study Post Graduate degree

    How would you describe yourself?

    What are your top 3 attributes?

    What are your vices? What holds you back?

    Is there anything missing in your life?

    What causes the most amount of stress in your life? What specifically creates that Stress?

    How do you relax or cope with stress? What do you do to cope with it?

    What is your greatest Fear? What is your greatest worry about the future?

    What drives you in life? What motivates you to achieve?

    What are you excited about in your life? What are you proud of?

    What’s most important in your life?

    What’s your primary focus in life? What do you put time and energy into?

    What do you value most in life? (Please place in sequential order all those that apply, #1 being most important.)
    Love Health Passion Achievement
    Approval Security Happiness Acceptance
    Approval Growth Adventure Intelligence
    Success Contribution Peace Recognition
    Joy Fun Making a Difference Respect

    What state(s) would you do almost anything to avoid? (Please place in sequential order all those that apply, #1 being most important.)
    Fear Loneliness Embarrassment Rejection
    Poverty Depression Humiliation Unappreciated
    Guilt Unloved Physical Pain Shame
    Anger Anxiety sadness Frustration

    What are you in control of? What are you responsible for? What is outside of your control?

    What do you believe about being successful? What does it take to be a success in life?

    What negative emotions do you experience a lot of?

    What emotions do you want more of?

    What do you believe about love?

    What do you believe about people?

    What do you believe about spirituality?

    What would be the greatest motivator to get you out of your comfort zone – A) your own growth/success, B) the growth / Success of others, C) other – please describe?

    How would you like to be coached? Would you like to be pushed, encouraged or both? How can the facilitators work with you to get the best out of you?

    What attributes would you look for in a facilitator?

    "Thank you! We look forward to working with you to "Change your MIND - Change your LIFE!"