30 Days to Transformation Registration Form

The 30 Days to Transformation Registration Form

Fill out the form carefully for registration
Student Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender*
Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Student E-mail*
example@example.com
Mobile Number*

Country CodeArea CodePhone Number
FacebookInstagramWord of MouthAdvertisement (Youtube, Facebook, Instagram)YoutubeOther
Marital Status*
Under $10,000 a year$10,000 - $30,000 a year$30,000 - $55,000 a year$55,000 - $100,000 a year$100,000 - $250,000 a yearOver $250,000 a yearI don't knowOther
On a scale of 1-10, how would you rate your current satisfaction with life in general? (1 being I'm not satisfied at all and 10 being I’m very satisfied)*
Why do you want to join this course? Please describe in detail. Also mention how long you have had this issue.*
What is your desired outcome from this course?*
What have you tried thus far to resolve this issue? Have you gone to therapy? Do you take medications for this?*
Do you indulge in recreational drugs? (usually people do this to run away from the pain of their life)*
Now think about some other areas of life that are a satisfaction level 7 or below. Please list each briefly and rate each of these.*
How would you rate your relationships in general? *
(1 being I'm not satisfied at all and 10 being I’m very satisfied)
Relationship with self (are you self critical,judgemental etc.)*
(1 being I'm not satisfied at all and 10 being I’m very satisfied)
Relationship with God (God loves me or God is mad at me etc.)*
(1 being I'm not satisfied at all and 10 being I’m very satisfied)
Relationship with Spouse
(1 being I'm not satisfied at all and 10 being I’m very satisfied)
Relationship with family (in-laws etc)*
(1 being I'm not satisfied at all and 10 being I’m very satisfied)
Relationship with colleagues/friends/ etc.*
(1 being I'm not satisfied at all and 10 being I’m very satisfied)
YesNo
yesno
YesNo
Anything else you would like to add?
Signature
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The 30 Days to Transformation Registration Form