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First name
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Last name
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Email
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Mobile phone number
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Street address
City
D.O.B (date of birth)
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Year
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Month
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Day
Gender (choose one)
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Female
Male
Other
What is your current marital status?
Married
Divorced
Single (not looking)
Single (looking)
Casual Dating
Do you have children?
No children
1 child
2 children
3 + children
What areas of your life do you want to improve? Check all that apply
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Career/Business
Finances
Spiritual/Personal Development
Love/Relationship/Marriage
Social Life
Physical Health
Organization of Home Environment
How long have you been feeling stagnant?
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Explain why you are ready for a complete life change?
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What do you hope to accomplish by getting your s**t together?
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By printing my full name electronically, I certify the information I provided on and in connection with this form is true and correct. I also understand that any false statements or deliberate omissions on this form may subject me to legal actions for fraudulent misrepresentation.
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Today's Date
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