Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Have you ever been coached before *

Check one

Yes

No

How do you prefer to be contacted *

Phone

Email

Both

Are you currently under the care of a therapist, social worker or psychiatrist?

Yes

No

How strongly do you agree with the following statement: "I am open and ready for my life to change." *

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Which of the following statements best describes your current life view? *

Pick Only One

Life's is Hard

Bad Things Happen & You Can't Do Anything About It

Life's Not Fair

Life Has No Remote, Get Up & Change it Yourself

Every Moment is An Opportunity

Why Dwell on the Past When We Only Have the Present

Life's a Box of Choices