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Your Name

Phone Number

Profession and Title

What are the first things that come to mind when you think about what’s not working with your professional life:

What are the first things that come to mind when you think about what’s not working with your personal life:

What actions or methods have you tried, now or in the past, to address the challenges you’re experiencing (ie. yoga, therapy, career counseling, books, etc.)

Why do you believe what you’ve done hasn’t worked so far?

Select the best choice that describes the primary issue that you wish to solve:

My leadership is failing and as a result my team is failing.

I’m not sure how to get my business to the next level.

I’m not sure I’m on the right path personally and/or professionally.

My relationships, business, physical and/or mental health are suffering as a result of trying to do too much and not having enough time/energy to get it all done. I feel like I’m doing so much, and failing at everything.

I am on the verge of burning out and fearful I may need to walk away soon. This is unsustainable.

I need help navigating my career so it doesn’t take a toll on my personal life.

I’ve lost my passion and would like to have energy, excitement and purpose again.

I’m stuck. I don’t know what’s next. I know something needs to change, but I’m not sure what it is.

Other

If you were to wave a magic wand, what would you like to see happen in your life- personally and professionally? What do you imagine that ideal situation might look like?

On a scale of 1-10, how committed are you to doing what it takes to learn how to have professional success and personal fulfillment at the same time?

Which type of support are you interested in currently?

Business Coaching

Team Coaching

Individual Coaching

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