Self Assessment Form

1
Name* This field is required.
First Name
Last Name
2
Age* This field is required.
3
Mobile* This field is required.
Please enter a valid mobile number.
4
Email* This field is required.
example@example.com
5
City* This field is required.
6
State* This field is required.
Andaman and Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chandigarh
Chhattisgarh
Dadra and Nagar Haveli
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Ladakh
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Puducherry
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttar Pradesh
Uttarakhand
West Bengal
7
Which of the following describes you best?* This field is required.
Businessman/Entrepreneur
Working Professional/Employee
Self-Employed/Freelancer
Student
Housewife
8
In which of the following areas you are struggling most?* This field is required.
Money & Finance
Business/Career
Physical Health
Mental Health
Relationship
Self Growth
Energy & Passion
9
Are you working hard for achieving your success and health, yet you are experiencing the patterns of failure, frustration, depression, anxiety, stress, lack of money, and diseases? * This field is required.
YESNO
10
Do you feel brain fog, mind clutter, tired and lack of motivation, drive, energy, and purpose?* This field is required.
YESNO
11
You know you have more in you and you are capable of achieving it but it’s not happening and you don’t know what is stopping you?* This field is required.
YESNO
12
What are the major obstacles stopping you from achieving your Dream life?* This field is required.
Stress, Anxiety & Depression
Insomnia
Sleeplessness
Panic Attack
Lack of Health, Energy & Passion
Lack of Focus, Concentration & Confidence
Lack of Decision Making & Courage
Habits
Overwhelm
Deep Regret/Guilt/Painful Memories
13
Specify your problem/issue:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
14
How badly are you committed to living your desired life?* This field is required.(On the scale of 1-5, where 1 = Not Committed and 5 = You badly want a solution ASAP)
1
2
3
4
5
15
Have you ever taken professional support to achieve your health, business, income, and relationship goal?* This field is required.
YESNO
16
What is your current monthly income?* This field is required.
No Income
25k or less
25k - 50k/month
50k-1 Lac/Month
1 Lac - 3 Lacs/Month
3 Lacs - 5 Lacs/Month
5 Lacs - 10 Lacs/Month
+10 Lacs Month
17
If you get an exact blueprint and support system to achieve your Health, Business/Career, Income, and Relationship Goal, how much you will be willing to invest in yourself? (The first session will be FREE!)* This field is required.
Money Doesn't Matter
50k - 1 Lac
25k - 50k
10k - 25k
5k - 10k
No I can't invest
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