Creation Code Coaching Questionnaire

1
Full Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Which area are you most interested in having a shift?* This field is required.
Becoming Your Best
Identifying Unconscious Blocks
Freedom from the Past
Feeling Connected
Self-Expression
Self-Worth
All of the Above
Other
5
Which best describes your current situation?* This field is required.
I want to reach the next level in my life.
I want to change my current circumstances.
I have specific challenges leaving me feeling stuck.
I need a complete breakthrough.
6
What do you feel is your main challenge?* This field is required.
7
Which best describes your Ideal Outcome regarding the breakthrough you would like to have?* This field is required.
Achieving my True Potential.
No longer affected by day-to-day circumstances.
Creating the Life I was meant to have.
Finally living my life Free from my Past
Peace & Fulfillment
8
If a mentor with a proven process advised me to invest $1,000 towards creating the life I want most, I would...* This field is required.
Do it, because I am spending at least that much between my personal life and business right now.
Do it, because I have the funds, I know what I need to hit my goals, and I am ready for a better life experience.
I would do it, but it would be a challenge affording that right now.
I would avoid at all costs because I do not believe my life can change, and I do not want to invest in myself, at all.
9
How soon are you committed to having a breakthrough?* This field is required.
Today - I am ready to create my Ideal Life now.
Within 30 Days - I am ready. I have a couple of things to do, and then I am ready to start.
Within 60 Days - I want to create these changes. I have a few things to take care of before I can start.
Within 90 Days - I know I need to do something. I have other commitments to complete first.
10
Which of the following best describes you?* This field is required.
I have the funds or credit to invest in creating my Ideal Life.
I have access to the funds or credit to invest in creating my Ideal Life.
I don't have immediate access to funds or credit, but I am resourceful and willing to do whatever it takes to get the funds required.
I do not have access to the funds or credit at all, and I want to keep my life exactly as it is now.
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