Mindset Coaching Questionnaire | Emotional Body Mapping | Mindfulness, Remote Healing and Self-care

Fill in the questionnaire below as honestly as you can so that our call can be as transformational as possible.

Contact Info

Name *

Name

First Name

Last Name

Skype ID / Facebook Messenger ID *

Current Situation

On a scale of 1-10, how are you feeling in your body? *

Where do you want to be in your body, mind and spirit? *

What are the main blockages stopping you from living a healthy lifestyle? *

Moving Forward

Right now I... *

Have the financial resources to improve my lifestyle

Have access to the financial resources to improve on my lifestyle

I don't have any financial resources and I am going to keep my lifestyle exactly where it is

If someone would tell me that in order to improve my current situation it requires the help of a mentor/coach I would... *

Know it's serves anyone who has been creating repeated unsuccessful results in their current lifestyle

Would be a little intimidated, but with the right mentor/coach, I would highly consider it because I am serious about the quality of my lifestyle

Avoid it at all costs because I want to be as cheap as possible

I will personally call you at the time you choose. Please commit to your appointment by typing this sentence in the box below: "Yes, I promise to answer the phone for my breakthrough session when my coach calls" *

Finally, on a scale of 1 to Bruce Lee, how awesome are you? *