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Next Level Success Questionaire
13
Questions
START
1
When it comes to making lasting change, what are you looking to change and what is the biggest challenge, frustration or problem that's getting in your way? (please be as specific as possible)
Check 1 Please
Self doubt
Not sure where to start
Motivation
Income
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2
Be honest and give yourself a score 1- 10
1=Not at all; 10=100%
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I have enough mental and physical energy needed to feel motivated, driven and accomplish everything I set out to accomplish on a consistent basis.
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I feel that I am clear about what my personal goals are and act on them daily/weekly
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I have enough mental and physical energy needed to feel motivated, driven and accomplish everything I set out to accomplish on a consistent basis.
I feel that I am clear about what my personal goals are and act on them daily/weekly
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3
What industry are you in/What do you do?
Choose 1 please
Self-employed
Employee
Not currently working
Prefer not to answer
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4
What are your top 3 focuses right now that you are working towards?
Choose up to 3 please
Education
More motivation
Being a better parent
Being a better partner
Increasing income
Purpose
Becoming an entrepreneur
Happiness
More confidence
More energy
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5
What obstacles or challenges do you believe have kept you from making progress on those previously mentioned focuses?
Choose up to 3
Time
Focus
Motivation
Effort
Where to start
Too many options
Need to roleplay
Self doubt
Need encouragement
Lack of support system
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6
When do you feel like your most successful and in your "zone"?
Choose up to 2
When you are taking action
When you have a goal
When you have accountability
When you have a plan
When you are making progress
When you have a coach/mentor
When you are in a group working
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7
What does your Ideal life look like, if at a snap of a finger you could get it?
Choose up to 3
More time
More freedom
A romantic partner/love
More money
Bigger house
More friends
Better car
More muscle
Lose weight
Personal time
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8
What stops you from having that life you mentioned above
Choose up to 3
Time
Focus
Motivation
Effort
Where to start
Too many options
Need to roleplay
Self doubt
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9
What repeating habits or patterns from the past, are you bringing to your present?
Choose up to 3
Poor follow through
Lack of effort
Lost interest
Overwhelm
Poor concentration
Lost focus
Distractions
Self sabotage
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10
Last Question: Evaluate yourself
1=Not at all; 10=100%
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My Current Energy Level - how would you rate this area of your life?
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My Current Relationships & Communication - Spending time with significant other, family, friends and/or coworkers who are supportive and with whom you communicate effectively.
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My hobbies - I regularly do things for myself
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Financial - I am where I expected to be at this point of my life
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Purpose - I know what my role is in this world
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My Current Energy Level - how would you rate this area of your life?
My Current Relationships & Communication - Spending time with significant other, family, friends and/or coworkers who are supportive and with whom you communicate effectively.
My hobbies - I regularly do things for myself
Financial - I am where I expected to be at this point of my life
Purpose - I know what my role is in this world
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11
What would you be willing to invest if you were to solve your challenges for good and optimize every area of your life that you're struggling with?
Check 1 please
$1000 - $3000
$3000 - $6000
> $6000
Other
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12
What's Your Name
Type below
First Name
Last Name
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13
What's Your Email?
No spam ever
example@example.com
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