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

Birthday:

Marital Status :SingleDivorcedMarriedSeparatedWidowed

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

Your occupation:

Employed By:

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.

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.)

What state(s) would you do almost anything to avoid? (Please place in sequential order all those that apply, #1 being most important.)

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?