Live Your Destiny Question Title 1. Do you have areas in your life you wish you could change? Such as unwanted behaviors, conflicts with family/friends/co-workers, money troubles, unsatisfied love relationships, career, etc.? Yes No If yes, what are the most important areas in your life, you'd like to change? Question Title 2. Do you currently believe it is possible for you can make permanent changes in any of these areas on your own? Yes No Have you ever succeeded when you've tried? Yes or No Question Title 3. Have you ever considered working with a professional to find out why or how to resolve these issues in your life? Yes No Question Title 4. If you have worked with a professional, what type of professional have you gone to?Check all that apply. Licensed Professional Psychologist Psychiatrist Spiritual counselor or Pastor Life Coach NLP Practitioner Hypnotherapist N/A Other (please specify) Question Title 5. If you worked with a professional to make changes in your life, did the changes last? Yes No If yes, what did you do to make those changes last? Question Title 6. What reasons have caused you to NOT seek professional help OR have caused you to hesitate when seeking a professional? Check all the reasons that apply. Costs too much My insurance didn’t/doesn’t cover it Unsure of how to select a professional I don’t have the time I don’t believe counseling works I don’t think I need professional help I can figure out my own problems People who seek professional help are mentally unstable, and that’s not me I don’t think my issues are something a professional could help me with It never occurred to me to seek help Nothing stops me in seeking a professional's help Other (please specify Question Title 7. If you learned there was a way to resolve an issue that was fast AND affordable, would you consider it? Yes No Question Title 8. What advertising most influences your decisions to select a service? Almost always Sometimes Not often Never Radio Radio Almost always Radio Sometimes Radio Not often Radio Never TV TV Almost always TV Sometimes TV Not often TV Never Internet Internet Almost always Internet Sometimes Internet Not often Internet Never Print - newspaper, magazine, flyers, etc. Print - newspaper, magazine, flyers, etc. Almost always Print - newspaper, magazine, flyers, etc. Sometimes Print - newspaper, magazine, flyers, etc. Not often Print - newspaper, magazine, flyers, etc. Never Coupons Coupons Almost always Coupons Sometimes Coupons Not often Coupons Never Drive by location Drive by location Almost always Drive by location Sometimes Drive by location Not often Drive by location Never Word of mouth Word of mouth Almost always Word of mouth Sometimes Word of mouth Not often Word of mouth Never Question Title 9. On the internet, how often do you visit these social networking sites? Daily 1-3 times per week 1-3 times per month 1-3 times per year Never Facebook Facebook Daily Facebook 1-3 times per week Facebook 1-3 times per month Facebook 1-3 times per year Facebook Never My space My space Daily My space 1-3 times per week My space 1-3 times per month My space 1-3 times per year My space Never YouTube YouTube Daily YouTube 1-3 times per week YouTube 1-3 times per month YouTube 1-3 times per year YouTube Never Twitter Twitter Daily Twitter 1-3 times per week Twitter 1-3 times per month Twitter 1-3 times per year Twitter Never Other (please specify) Question Title 10. About you... Name Sex (Male or Female) Age Marital status Zip Code email address Done