Hello, dear Quantum Coachee!
Please answer the questions below and rate yourself at the beginning of this program. At the end you will repeat the assessment and see what changed! Your answers will be automatically sent to you for your own reference to the nominated email address. Have fun!
Name
*
First Name
Last Name
Email Address
*
Please use the e-mail you used to sign up for the program
Birthdate
-
Month
-
Day
Year
So we can congratulate you :)
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City (to identify timezones)
Country (to identify timezones)
Postal / Zip Code
From 1-10 (ten being the best), please rate the following where you are right now, before the program starts:
*
BEFORE
SELF-LOVE – Physical health & fitness
1
2
3
4
5
6
7
8
9
10
SELF-LOVE – Mental & emotional health
1
2
3
4
5
6
7
8
9
10
SELF-LOVE – Putting yourself first (when needed)
1
2
3
4
5
6
7
8
9
10
SELF-LOVE – Self-care (time & energy allocated)
1
2
3
4
5
6
7
8
9
10
SELF-LOVE – Your physical environment
1
2
3
4
5
6
7
8
9
10
INTIMACY & ECSTACY – In-to-me-I-see
1
2
3
4
5
6
7
8
9
10
INTIMACY & ECSTACY – Feeling loved
1
2
3
4
5
6
7
8
9
10
INTIMACY & ECSTACY – Being able to express love
1
2
3
4
5
6
7
8
9
10
INTIMACY & ECSTACY – Adventure in sex/passion
1
2
3
4
5
6
7
8
9
10
INTIMACY & ECSTACY – Growing together
1
2
3
4
5
6
7
8
9
10
WEALTH & CONTRIBUTION – Satisfaction in work/career
1
2
3
4
5
6
7
8
9
10
WEALTH & CONTRIBUTION – Sense of contribution through work
1
2
3
4
5
6
7
8
9
10
WEALTH & CONTRIBUTION – Purpose & creative fulfillment
1
2
3
4
5
6
7
8
9
10
WEALTH & CONTRIBUTION – Investments/wealth growth
1
2
3
4
5
6
7
8
9
10
WEALTH & CONTRIBUTION – Making money (in general)
1
2
3
4
5
6
7
8
9
10
TRIBE & ADVENTURES – Family
1
2
3
4
5
6
7
8
9
10
TRIBE & ADVENTURES – Friends
1
2
3
4
5
6
7
8
9
10
TRIBE & ADVENTURES – Sense of Belonging
1
2
3
4
5
6
7
8
9
10
TRIBE & ADVENTURES – Celebrations
1
2
3
4
5
6
7
8
9
10
TRIBE & ADVENTURES – Adventures
1
2
3
4
5
6
7
8
9
10
PLAY & GROWTH – Time spent on hobbies
1
2
3
4
5
6
7
8
9
10
PLAY & GROWTH – Learning new things
1
2
3
4
5
6
7
8
9
10
PLAY & GROWTH – Clarity & Execution (of personal projects)
1
2
3
4
5
6
7
8
9
10
PLAY & GROWTH – Playfulness
1
2
3
4
5
6
7
8
9
10
PLAY & GROWTH – Creativity
1
2
3
4
5
6
7
8
9
10
What are your top 5 results from the subconscious masks assessment? Please also add the percentages.
On a scale from 1 to 10, how accurate to you perceive the results to be?
Not accurate at all
1
2
3
4
5
6
7
8
9
Fully accurate
10
1 is Not accurate at all, 10 is Fully accurate
Please give specific examples supporting your answer to the question above.
What are the most defining experiences in your life?
You can keep it shorter by focussing on the facts (cause and effects) rather than going into interpretation.
Age 0-7
Age 8-12
Age 13-19
Age 20+
Looking at the experiences in your life, what are the things that you want to change?
List any health challenges throughout your life (please add at what age). Focus on the symptoms, not just the medical terms.
What triggers you?
What angers you?
What brings you joy?
What 3 primary things do you want to achieve in this mastermind?
Who is your Quantum Coach?
Please Select
Anna Berger
Joyce Dickerson
Becky Salter
Daniela Dalalau
Filipe Pereira
Fina Teran
Margarita Martínez
Vanessa Fernandez
Jill Cochran
Reena Kukreja
Valeria Fontana
Elisabetta Scarabelli
Kylie Smart
Eva Romanowska
Erica Kelly
Peter Matter
Tebs Sebastian
Rhonda Chiljan
Cameron Merchant
Danielle Martin
Jazzy Melhop
Vijay Singhera
Christina Perry
Gary Smart
Govind Cooke
Sharon Sessions
Annette Pieper
Heather Russo
Ella Warchol
Kirsten Gunning
Submit
Should be Empty: