Life In Luxe Information Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Which promotion, product or service brought you to this page?* This field is required.
5
What about it interested you the most?* This field is required.
6
How interested are you in moving forward with this promotion, product or service?* This field is required.
1
2
3
4
5
Kinda
When Do I Get Started?
7
Are you interested in losing weight?* This field is required.
YESNO
8
If you answered yes, how much would you like to lose?* This field is required.
9
Do you have a target date/event you are working towards and if so, when is it?* This field is required.
10
Are you interested in having more energy?* This field is required.
I'm Deprived Of Energy - Heck yes
A little more would be nice...
I'm already like the energizer bunny
11
Would better mental clarity benefit your life?* This field is required.
YES
I'm not sure, so probably
Nope, I'm Sharp as a whistle
12
Would better sleep benefit your life?* This field is required.
Sleep? Who Sleeps?
I Could use a little better sleep
Nope, I get plenty of great sleep every night
13
Would you like better hair health, including longer thicker, stronger hair?* This field is required.
Heck yeah
I could use a little help
Nah, my hair, sin and nails are all amazing goddesses
14
Do you feel you could use less stress in your life?* This field is required.
Please help... Stress is my middle name
A little less stress would be nice
I'm cool as a cucumber, not stressed at all
15
How would you rate your weekly physical activity * This field is required.
1
2
3
4
5
Couch Potato
Gym Rat
16
How would you rate your eating habits?* This field is required.
1
2
3
4
5
French Fries Are My Best Friend
Salad Lover
17
How would you rate your self care routine?* This field is required.
1
2
3
4
5
Huh? What's Self Care?
All Day, Every Day Baby!!
18
What is your work-life like?* This field is required.
Job Free
Part-Time
Stay-At-Home-Mama
Full Time
19
Whichever box you checked above, do you truly love it and feel fulfilled at the end of the day?* This field is required.
Yes
No
I hadn't really thought about it...kinda?
20
Are You A Mama?* This field is required.
YESNO
21
If Yes, How many Kids* This field is required.
1
2
3
4+
22
Are You Interested In Making More Money?* This field is required.
Girl, Yes!
Nah, I'm financially set and feel fulfilled
Hmmm, maybe
23
If you could pick 1 or 2 goals to focus on, what would they be?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
24
Tell me about you! Anything additional that may help me, help steer you in the right direction and truly be able to recommend only the best of what pertains to you, please share below. Anything that comes to mind, lay it out there!* This field is required.
Huge
Large
Normal
Small
Ok
Ok
25
How ready are you to invest in yourself?* This field is required.
1
2
3
4
5
I don't know
I was ready yesterday!
26
If I were to call you, when are the best times to reach you?* This field is required.Please choose all that apply
Anytime, day or night, weekends too
Only Weekdays
Only Weekends
Morning: 7am - 11am
Mid-Day: 11am - 2pm
Afternoon: 2pm - 6pm
Evening: 5pm - 9pm
27
Which Contact Method Do You Prefer* This field is required.
Phone Call
Text Message
Other
28
What Social Media Platforms Are You Currently On?Please Choose All That Apply
FaceBook
Instagram
Pinterest
You Tube
Tik Tok
Twitter
All Social
Other
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