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Assessment Form
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17
Questions
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1
Name
*
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Mr.
Mrs.
Ms.
Mr.
Mr.
Mrs.
Ms.
Prefix
First Name
Last Name
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2
Age
*
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-
Date
Year
Month
Day
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3
Phone Number
*
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Please enter a valid phone number.
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4
Email
*
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example@example.com
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5
Address
*
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Street Address 1
Street Address Line 2
City
State
Zip Code
India
Country
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6
Which of the following describes you best?
*
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Businessman/Entrepreneur
Working Professional/Employee
Self-Employed/Freelancer
Student
Housewife
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7
Are you working hard to achieve success and health, yet you are experiencing patterns of failure, frustration, depression, anxiety, stress, a lack of money, and diseases?
*
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YES
NO
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8
In which of the following areas you are struggling most?
Money & Finance
Business/Career
Mental Health
Relationship
Self Growth
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9
Do you feel brain fog, mind clutter, tired and lack of motivation, drive, energy, and purpose?
*
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YES
NO
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10
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?
*
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YES
NO
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11
What are the major obstacles stopping you from achieving your Dream life?
*
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Stress, Anxiety & Depression
Overthinking
Sleeplessness
Panic Attack
Lack of Health, Energy & Passion
Lack of Focus, Concentration & Confidenc
Lack of decision-making and courage
Habits
Overwhelm
Deep Regret/Guilt/Painful Memories
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12
Tell us more about challenges/issue:
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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13
How badly are you committed to living your desired life? (On the scale of 1-10, where 1 = Not committed and 10 = You badly want a solution ASAP)
*
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1
2
3
4
5
6
7
8
9
10
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14
Have you ever taken professional support to achieve your health, business, income, and relationship goal?
*
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YES
NO
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15
Do you have someone to support you in your family that you should come out of current challenges
YES
NO
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16
What is your current monthly income?
*
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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
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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!)
*
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Money Doesn't Matter
50k - 1 Lac
35k - 50k
20k - 35k
15k - 20k
No I can't invest
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