Questionnaire Application
For Mentorship
Instructions:
Please answer ALL of the questions to the best of your ability. These questions help me get to know your goals & desires and understand how you are currently performing. Once submitted, I will review and let you know if you qualify. Please allow a few days for the review.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Date of Birth
*
Please briefly describe how you heard about my mentorship and why you are applying
*
Please rate yourself in the following areas of your life on a scale of 1 (lowest) to 10 (highest):
Clarity: Do you feel you are clear about who you are, your purpose, and the direction you want to go in life?
*
Not At All
1
2
3
4
5
6
7
8
9
Very Clear
10
1 is Not At All, 10 is Very Clear
Energy: Do you consistently have enough mental and physical energy needed to excel, accomplish your goals, and feel motivated and happy?
*
No Energy
1
2
3
4
5
6
7
8
9
All the Energy in the World
10
1 is No Energy, 10 is All the Energy in the World
Courage: Do you take action and consistently express who you truly are and what you truly think, need, and desire with the world?
*
Never
1
2
3
4
5
6
7
8
9
Always
10
1 is Never, 10 is Always
Productivity: Are you consistently focused and effective, and are you good at minimizing distractions and maintaining priorities?
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Never
1
2
3
4
5
6
7
8
9
Always
10
1 is Never, 10 is Always
Influence: Do you feel you have the social influence with your family, friends, and team needed to accomplish your goals?
*
Not at All
1
2
3
4
5
6
7
8
9
Absolutely 100%
10
1 is Not at All, 10 is Absolutely 100%
What do you do for a living, and why did you choose that?
*
What are the top 3 goals you are striving to achieve right now?
*
What major stressors or challenges are you struggling with right now?
*
When you feel like your most successful and happy self, what makes you feel that way?
*
What would your dream life look like if you could wave a magic wand and make it happen?
*
What else has prevented you from having that dream life?
*
What goal or dream have you ever given up on or failed at?
*
What 3 big changes would you like to make in your life in the next 12 months?
*
What are you most proud of and excited about in your life?
*
Why would you like to work with me as your coach?
*
Submit
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