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Welcome, you're standing at the edge of a breakthrough.
This is your moment to confront what's been holding you back and claim the life you deserve. Be bold, be honest—this is where your transformation begins.
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1
What's the dream you've been ignoring?
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Describe the biggest goal or aspiration that you’ve been putting off. This is your moment to name what you truly want.
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2
Why haven't you pursued this dream?
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Be brutally honest. What fears, doubts, or obstacles have kept you stuck?
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3
How is stalling negatively impacting your life?
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Detail how this indecision is affecting your mental state, happiness, and day-to-day well-being. Consider the broader consequences—relationships, career, health. How is not acting holding you back?
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4
Complete This Sentence: "I’m tired of waking up every day feeling __________."
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5
How is this stagnation impacting you? (Check all that apply)
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Stressed
Feeling trapped
Stuck
Burned out
Restless
Distracted
Empty
Guilty
Ashamed
Insecure
Seeking approval
Hard on myself
Strained relationships
Apathy
Cynicism/Overly Critical
Reduced Creativity
Detachment
Difficulty Concentrating
Angry
Sad
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6
What health issues are you facing? (Check all that apply)
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Anxiety
Chronic Pain
Depression
Restlessness
Brain Fog
Panic Attacks
Fatigue
Headaches
Digestive Issues
Insomnia
Heart Palpitations
Other
Other
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7
Have you experienced any of the following traumatic events? (Check all that apply)
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Accidents or Natural Disasters
Loss of a Loved One
Medical Trauma
Assault
Emotional Betrayal
Divorce/Ending of Significant Relationship
Other
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8
How do you feel these traumatic events have impacted your emotional well-being and your ability to cope with life's challenges?
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9
What past events do you replay over and over?
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10
What aspects of yourself do you dislike?
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11
Now, let's shift focus for a second. What's something you excel at?
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12
What achievement(s) are you most proud of?
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13
Now, let's look to present day. What triggers do you often find yourself reacting to? (Check all that apply)
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Specific people (e.g., family, friends, coworkers)
Emotional states (e.g., stress, loneliness)
Environmental cues (e.g., places, dates)
Thoughts or memories
Relationship dynamics (e.g., conflict, intimacy)
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14
What are the consequences if you don't change? (Why now?)
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Picture your future if nothing changes. Why is now the crucial moment to break free?
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15
What methods or programs have you tried before, and why do you think they didn’t work for you?
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16
What are you willing to do to transform your life?
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Define the lengths you're prepared to go to for a real, lasting change.
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17
On a scale of 1-10, how committed are you to actively participating in the program and doing the necessary work for your healing and growth? (1 being not committed, 10 being fully committed)
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18
Are you ready to invest the time, energy, and finances to change your life now if the solution we offer is right for you?
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Yes! I must change now—my future depends on it.
No, I’ll just wait and hope things magically get better.
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19
What's your name?
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First Name
Last Name
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20
What's your email address?
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We will use this to reply to you.
example@example.com
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21
What's your phone number?
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We'll use this to send you updates to your application status.
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