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Surname
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Given Name
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E-mail
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Phone Number
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Please describe biggest challenge right now that you are seeking help with?
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What have you previously tried to resolve this issue - and what was the result?
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On a scale of 1 to 10 how important is it for you to resolve this problem in the next 6 months?
1
2
3
4
5
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9
10
Not very important
It's imperative
1 is Not very important, 10 is It's imperative
Please indicate 2 or 3 possible times for me to call you during the next week or two for a 20 minute conversation about these issues (days and times).
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I am reserving this time to speak to you. Although there is no cost for this appointment please respect it as if it was a paid consultation
Please confirm by typing "I confirm"
Is there anything else you would like me to know?
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