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22
Questions
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1
I Want More Peace in My Life
YES
NO
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2
Regarding Relationships...
Check all that apply
I want better romantic relationships
I want to start dating people who treat me like I am a treasure (if single)
I want a vibrant, fulfilling marriage
I want better quality friendships
I want close relationships with my children (if applicable)
I want to mend important family relationships
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3
Concerning Confidence...
Check all that apply
I want more Confidence in my social circles to speak up and participate more
I want Confidence to do the thing I've thought about for years but haven't taken the leap
I want Confidence in my career, in my own skills and value, in getting promotions
I want Confidence to pursue my gifts and dreams, to shine
I want Confidence to face my fears and put them behind me
I want Confidence to become the person I always hoped I could be
I want Confidence to find my voice and speak up more
I want to believe in myself and my future
Other
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4
Regarding Your Personal Health...
Check all that Apply
I want to release extra pounds
I want to find natural ways to manage my blood sugar
I want to feel like getting up in the mornings
I want to move my body more
I want to get better sleep
I want to eat healthier foods that are actually satisfying and help me feel GREAT
I want to look younger and healthier
I want to move without hurting
I want to fit in smaller clothes without any bulges
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5
Regarding My Past Baggage...
(Without Needing to Re-Live It, Please!)
I want to be free from non-rational negative emotions based on past trauma
I want to stop focusing on the past and be able to enjoy today
I want to release unreasonable feelings of anger, fear, sadness, guilt, or hurt
I want to believe in my future and not feel held captive by my past
I want to feel worthy of all I hope for
I want to stop putting myself and others down
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6
What Do You Think Most Holds You Back from Achieving Your Goals?
Choose ALL that APPLY
Fear
Procrastination
Habits
Lack of Motivation
Low Self-Esteem
Anger
Blaming
Indecision
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7
How Much Do You Want a New, Joyful Life for Yourself?
1-10 where one is I Don't Care and 10 is I ABSOLUTELY Want This Now!
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8
What Have You Tried?
Choose ALL that APPLY
Traditional Therapy and Counseling
Support Groups
Personal Development Courses/Coaches
Self-Help Books
Prayer
Meditation or Scripture Study
Friends, Neighbors, and Colleagues' Counsel
NLP
TimeLine Therapy
Hypnosis Therapy
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9
What Has and HAS NOT Worked Well So Far? What Has This Cost You?
Please Describe
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10
What Do You Think Really Holds You Back from Achieving Your Goals?
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11
Which of These Might Be Most Helpful Right Now?
Choose ALL that APPLY
Releasing Emotions for Good
Overcoming Indecision
Overcoming Fear
Learning to Trust Myself
Remove Obstacles to Success
Anchoring in Success Attributes
Improving My Health
Becoming Clear on My Goals
Accountability
Other
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12
Which Parts of NEW JOYFUL LIFE: Healing Hearts with NLP Would Help Most?
Choose ALL that APPLY
Release Inhibiting Emotions from Past Trauma without reliving traumatic events
Overcome Indecision and Rewire My Brain with CONFIDENCE
Release Anxiety or Phobias
Improve My Health and Fitness
Create Inner Trust and PEACE
Anchor in Attributes for Success
Become the person I WANT TO BE!
Create the Life of My Dreams!
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13
What Is Your Current LIFE SATISFACTION?
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Row 0, Column 4
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14
How Committed Are You to Investing Time and Resources to Achieve Your Goals?
1 Is NOT Committed, 5 Is FULLY Committed
1
2
3
4
5
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15
What Vision Do YOU Have for YOUR FUTURE?
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16
Name
First Name
Last Name
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17
Email
example@example.com
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18
Phone Number
Please enter a valid phone number.
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19
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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20
What Is Your Age Range?
Choose One
18-29
30-39
40-49
50-59
60-69
70+
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21
Current Marital Status
Choose One
Single, Never Married
Divorced
Widowed
Married
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22
Appointment
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