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1. Describe your current relationship status.

* 2. How many children do you have, do they live with you and what are their ages?

* 3. Do you currently have a support system in place: family/friends, counselor or clergy? Kindly explain your situation in detail.

* 4. Describe your employment circumstances, salary range and level of education.

5. How long have you been a single mom?

* 6. What is your biggest challenge as a single mom?

7. Describe your self-esteem in 3-5 sentences.

* 8. If you had enough support, what would you attempt to do? Describe your most important goals

* 9. Tell us why you should be chosen for Success & the Single Mom 100-Day Action Program, and share your level of commitment to completing the Program. Kindly leave your name, email and phone number for us to contact you, if you are chosen.

10. This Program is being provided at no cost to the participants. In exchange, you will allow us to use your case study (anonymous if requested) in our upcoming book. You will also be required to sign Non-Disclosure and Confidentiality Agreements. Kindly confirm "yes" if you agree to these conditions.

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