First Name*

Last Name*

Email*

Phone Number*

What brought you to seek help?*

What is your biggest barrier to accepting help?*

What do you want to accomplish in this process?*

What solutions have you tried in the past? What were the results?*

What would not having this problem mean to you?*

Is there anything you think I need to know about you before our call?*

How ready are you to get started?*

A. I am 100% ready to do what it takes and have the time and the financial resources to focus my energy on solving these problems.

B. I am 70% ready to do what it takes and have access to the financial resources to invest in my future and emotional well being. I’m just not sure I have the time.

C. I am not really ready and I don’t have any time or money or real desire to do anything to change. I just want the easiest way to a quick solution.

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