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Name ^*

First Name*

Last Name*

Email ^*

Email*

What is your IG handle? (I will use this to communicate with you)*

What is your age and marital status?*

What is your current occupation?*

Do you have a spouse or someone who is involved in your decision making process?*

Yes, I have a spouse/ partner involved in my decision making process

No, I don't have anyone else that needs to be involved in my decision making process

Yes, I have a family member or someone else involved in my decision making process

If we work together, what would you like to see happen?*

Are you currently working or in school? Do you have career or educational goals that you're having trouble achieving?*

Do you feel like you're struggling with an intimate relationship or getting into a relationship?

Have you ever worked with a coach before?*

This mentorship gives you every tool and resource to reach your goal and sustain the results. With that said, are you in a place that you can currently invest in a coach if we are a great fit to work on this together? (monthly budget, savings, credit cards, loans, paypal credit)*

Yes, I'm ready to invest in myself

No, I'm not ready to invest in myself

If you found a program that could teach you how to break your self-sabotaging patterns for good and find peace, and joining that program required an investment, how would you fund that investment?*

I would use income from my job, or my spouse's job

I would use a credit card, paypal credit or another type of loan

I would borrow money from someone in my family or inner circle

I have terrible credit/ no access to funds so this is not an option for me

Other

On a scale of 1-10, how committed are you to taking the necessary steps to reaching your goal and up-leveling your life?*

If accepted how soon are you looking to get started? (I expect those who apply to be ready to move forward ASAP)*

Where did you find me? How did you hear about Healing Self-Sabotage/ Break Free? (i.e. showed up as suggested on feed, sponsored post, Google, a friend, etc)*

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