First Name

    Last name

    Email

    Mobile

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

    Birthday:

    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

    Other

    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, breakthrough or reinforce?
    1.
    2.
    3.

    How would you know if you achieved them?

    Please describe your most successful achievements to date:
    1.
    2.
    3.

    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?
    1.
    2.
    3.

    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

    Faith

    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

    Failure

    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?

    "Thank you! I look forward to seeing you soon!