Personal Services Questionnaire

Full Name (required)

Email (required)

Contact Phone Number/Skype ID

Interested In (select all that apply):

Please respond to the following questions with as much detail as you like. Your information is 100% confidential, and all submissions are seen ONLY
by me.
The more information you provide, the better I will get to know you and the more powerful our work together will be.


Background (required): Tell me about yourself. What do you do for work? What do you do for fun? What does your average week look like?
What does your social life look like?


Your Goals (required): Name one, two, or three BIG things that you want to overcome or achieve from our work together.


Your Obstacles (required): Look at your goals above. How close are you toward reaching your goals? What is holding you back right
now from getting there, and how? What or who is supporting your toward each goal (if any) and how? Please be detailed.


Your Success (required): What does real success look like to you? If you accomplished or lived out each of your goals above, what would be
different? How would you feel? What would you be doing and what direction would your life be moving in?


Anything else?
Please write out anything else you want me to know about before we talk. Everything you share is 100% confidential and the better I know and understand you, the better our work together will be.

(All submissions delivered directly and exclusively to my personal inbox.)