You can always press Enter⏎ to continue
Client Application Form 2
1
Previous
Next
Submit
Press
Enter
2
Let's get started. Which of the Following Best Describes You?
*
This field is required.
Married with Children
Married - No Children
Not Married with Children
Not Married - No Children
Previous
Next
Submit
Press
Enter
3
Great, can we get
your full name?
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
4
Awesome {greatCan:first}, Do you run and operate your own business?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
5
That's fine. We work with a tonne of high performing men who have high pressure jobs. Are you currently employed or working?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
6
Alright {greatCan:first}, we also coach a small portion of men who are not currently working. We have heaps of free content we can send you however the point of a breakthrough session is to create a coaching program and potentially coach you as a paid client. Are you currently in a position to invest
time & money
into yourself?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
7
Rate your current
HAPPINESS & FULFILMENT
out of 10
*
This field is required.
1
2
3
4
5
6
7
8
9
10
Terrible
Amazing
Previous
Next
Submit
Press
Enter
8
Rate your current
RELATIONSHIPS
out of 10
*
This field is required.
1
2
3
4
5
6
7
8
9
10
Falling Apart
Better Than Ever
Previous
Next
Submit
Press
Enter
9
What are your biggest problems and challenges you are facing in
health, wealth and relationships?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
10
What are the
roadblocks and excuses that have been holding you back?
Write down
all of the things
that have stopped you.
*
This field is required.
Previous
Next
Submit
Press
Enter
11
{greatCan:first}, how
LONG
has this been an issue for you?
*
This field is required.
Previous
Next
Submit
Press
Enter
12
What has it cost you
in the past by not moving past these challenges? What will it cost you in the future if you don't change
RIGHT NOW
?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
13
What do you want to achieve in the next 8 weeks with your
BODY/HEALTH
?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
14
What do you want to achieve in the next 8 weeks with your
BUSINESS/WEALTH
?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
15
What do you want to achieve in the next 8 weeks with your
RELATIONSHIPS
?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
16
What is your ultimate
WHY
! Get
DEEP
on
WHY
this is so important to you and your loved ones.
WHY MUST YOU GET YOUR LIFE ON TRACK?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
17
Who do you love/care about that will deeply benefit when you become
THE EMPOWERED
version of yourself that achieves these things?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
18
What would it be worth to you and your loved ones in the future if you achieve these goals by investing in YOU?
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
19
If selected for coaching how committed are you to going
ALL IN
and becoming
THE EMPOWERED MAN
for yourself and your loved ones?
*
This field is required.
1
2
3
4
5
6
7
8
9
10
Not At All
COMMITTED AS FUCK!
Previous
Next
Submit
Press
Enter
20
If you are selected for Empowered Man Coaching, how much are you
willing to invest in our coaching
and your own personal development to achieve your goals?
*
This field is required.
$2500+
$5000+
As much as it takes to succeed
I am not willing to invest in myself right now
Previous
Next
Submit
Press
Enter
21
And what's your
email address?
A copy of your application will be sent to you.
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
22
Awesome {greatCan:first}. Almost done,
what's your best contact number?
We will contact you on this number if your application is successful.
*
This field is required.
Previous
Next
Submit
Press
Enter
23
Cool, last question... What city/state are you in? (so I don't wake you up)
*
This field is required.
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
23
See All
Go Back
Submit