Jenerator Program
Information
Name
First Name
Last Name
Address
Phone Number
-
Area Code
Phone Number
E-mail
On a scale of 1-10 how ready are you to make a change in your life?
Have you ever done any transformational or personal development training in the past?
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Part II: Background Information
Please tell me what your ultimate goal in working with me as your coach. What will your life feel and look like?
Why now? Why is this the right time for you to reach your vision?
Please tell me a bit about your work/life balance? What does a typical day look like for you?
Please tell me a little bit about your vision.
Do you have anything in your life that will prevent you (support/money/time) that will from reaching your vision?
Please describe your current day to day activity level? What are your workouts, schedule, and day to day routines?
Are you married or in a committed partnership?
Do you currently have a source of income?
Would you describe yourself as a healthy person?
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Have you ever suffered from a diagnosed mental illness?
Have you ever suffered from an eating disorder? If so please explain in detail.
Are you ready to fully commit to reaching your goals and empower yourself?
Yes
No
Is there anything else you would like me to know?
Submit
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