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
Where did you hear about the course?*

FacebookInstagramWord of MouthAdvertisement (Youtube, Facebook, Instagram)YoutubeOther
Marital Status*
What is your household income level per year in USD (this is to help Eram understand what problems you might be facing)*

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)
Is this your first time taking an Eram Saeed course?*

YesNo
One of the most important elements of such a session are the person's ability to be completely truthful. Eram can’t help you as effectively if you are not honest about the events and your own feelings. She doesn’t judge anyone based on what they share as she is there as a guide, not a judge. Are you able to trust Eram and share with honesty?*

yesno
I agree to all the terms and conditions of participating in a course from Eram Enterprises INC*

YesNo
Anything else you would like to add?
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The 30 Days to Transformation Registration Form