Clone of Workshop Survey

1
Full Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
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Phone Number
Please enter a valid phone number.
4
After Authentic Me, what would feel noticeably different in your day-to-day life? * This field is required.Think about decisions, peace, confidence, relationships, and/or self-respect.
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What would it feel like to choose yourself—consistently—for the next 16 weeks?* This field is required.
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Which parts of your life are feeling weight right now?
Self-respect
Time/energy
Relationships
Confidence
Boundaries
Happiness
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What are you ready to create in your life right now? Why does this matter to you?* This field is required.
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If nothing changes this year, what’s at stake for you?* This field is required.
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What’s the story you’ve been carrying that is shaping your choices?* This field is required.
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What do you know is true about you that you’ve been negotiating with? * This field is required.
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What does authentic you look like in action? List 3–5 specific behaviors you’d be living out. * This field is required.
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Where do you abandon yourself most often? * This field is required.Examples: relationships, work, parenting, body, money, boundaries, voice
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What does it look like for you?* This field is required.
I say yes when I mean no
I explain myself too much
I withdraw / go inward
I take on too much responsibility
I avoid the conversation or decision
I react emotionally, then regret it
I distract myself to not feel it
Other
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What’s the #1 pattern you’re done repeating? (Be honest.)* This field is required.Examples: relationships, work, parenting, body, money, boundaries, voice
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If you trusted your own voice: what would you do more of?* This field is required.
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If you stopped needing approval: what would you do less of?* This field is required.
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What’s one boundary you’d hold without guilt if you felt grounded and confident?* This field is required.
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18
What support helps you follow through best?* This field is required.
Short daily videos
Journaling/prompts
Worksheets
Action Steps
Live coaching
Community
Accountability
1:1 Support
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What tends to make you disengage?* This field is required.
Too much information
Not enough structure
Fear of being seen
Perfectionism
Live coaching
Losing momentum
Life gets busy
Not seeing change fast
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Are you ready to?* This field is required.Scale: 0 = Not true / 10 = Completely true
I’m ready to stop repeating the same patterns.
I’m willing to be honest with myself, even when it’s uncomfortable.
I can protect 15–60 minutes/day for this work.
I’m willing to learn how to trust myself.
I’m ready to follow through even when I don’t feel confident yet.
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I’m ready to stop repeating the same patterns.
I’m willing to be honest with myself, even when it’s uncomfortable.
I can protect 15–60 minutes/day for this work.
I’m willing to learn how to trust myself.
I’m ready to follow through even when I don’t feel confident yet.
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
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Where are you now? Where do you want to be?* This field is required.
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Goal In 16 Weeks (1-10)
Self-trust
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Confidence
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Consistency
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Boundaries without guilt
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Your voice - speaking up
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Emotional steadiness
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Self - respect
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Decision making
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Self-trust
Confidence
Consistency
Boundaries without guilt
Your voice - speaking up
Emotional steadiness
Self - respect
Decision making
Now (1-10)
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Goal In 16 Weeks (1-10)
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Now (1-10)
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Goal In 16 Weeks (1-10)
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Now (1-10)
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Goal In 16 Weeks (1-10)
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Now (1-10)
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Goal In 16 Weeks (1-10)
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Goal In 16 Weeks (1-10)
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Now (1-10)
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Goal In 16 Weeks (1-10)
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Goal In 16 Weeks (1-10)
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Goal In 16 Weeks (1-10)
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If we could help you solve ONE thing in the next 16 weeks, what would make this worth it?* This field is required.
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23
Additional thoughts?
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