The Centered CEO™️ Intensive – Application
Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Company Qualification
Annual Revenue
*
Please Select
Under $5M
$5M–$10M
$10M–$25M
$25M–$50M
$50M+
Number of Employees
*
Please Select
1–10
11–25
26–50
51–100
101–500
500+
Your Role / Title
*
Industry
*
Diagnostic Questions
Tell me about your business and current role
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0/250
What specific problem, decision, or pattern prompted you to apply?
*
0/300
What feels stuck, heavy, or chaotic in your leadership right now?
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0/300
Complete this sentence: "I know I should ____, but I keep ____."
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0/200
What are you doing that someone else should be doing?
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0/300
When things get stressful, what’s your default response?
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0/300
Readiness Assessment
Are you ready for direct, uncomfortable feedback?
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Yes, I want the truth
No, I prefer gentler feedback
Not sure
After this session, what happens next?
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I’ll implement immediately
I’m still exploring options
Depends on what I hear
Investment Acknowledgment
*
I understand this is a $5K or $15K–$18K investment, and I am prepared to make this decision within 72 hours of being approved.
Which session format are you most interested in exploring? (Final session recommendations are determined after application review.)
*
2-Hour Private Virtual Session ($5K)
4-Hour Deep Dive ($15K)
6-Hour Deep Dive ($18K)
I’m unsure and open to guidance
Logistics
Preferred format
*
Virtual
In-Person (Phoenix area)
In-person (client location; travel arranged as needed)
Flexible
How did you hear about this?
*
Please Select
Referral
LinkedIn
Speaking Event
TEDx
Google
Other
Referral Name (if applicable)
Additional Context You'd Like to Share (optional)
Application Status:
Submit
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