Breakthrough Questionnaire
…the start of our work together
Full Name
*
Prefix
First Name
Last Name
E-mail
*
Birthday Month & Year
Motivation
What motivated you to sign up for the program?
What is the greatest challenge or impediment to identifying or actualizing your true calling? (If different from Above).
How motivated are you to create a change in your life?
Please choose which best describes your current state of readiness:
I am not ready to create a change in my life
I am possibly motivated to create a change in my life
I really want a change in my life but am afraid of change
I really want a change in my life but I don’t know how to make it happen
I am ready and excited to create a change my life now
Intention
Please indicate at least one tangible outcome or measurable shift you want to see in yourself, in your life or how you approach your life, as a result of our work together?
Clarity
Please indicate what is true for you:
I know what my mission is but I’m not living it; I need support to actualize it.
I don’t know what my mission in life is; I would like help getting clarity and identifying it.
Lifestyle
Why is it important for you to actualize your life’s mission?
How would your life be different if you were living your mission in the world?
Please indicate which of the following feelings best describes you?
Bored
Stressed Out
Unhappy
Frustration
Stagnation
Apathy
In a Crisis
Trapped
Restlessness
Feel Stuck
You Feel Like Something is Wrong
A Deep Yearning Is this all there is to life?
Do you want your life to be different than it currently is? Please elaborate.
Are you happy with your current occupation?
What changes if any would you like to see in the arena of work?
Please use the space to share anything else you would like us to know.
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