Disrupting the Ordinary Survey

1. Where do you want to be in a year? If one year from today, you were looking back on this year, what would you like to have accomplished?

Where do you want to be in a year? If one year from today, you were looking back on this year, what would you like to have accomplished?

2. What would be a breakthrough goal for you? What will accomplishing this goal provide for you?

What would be a breakthrough goal for you? What will accomplishing this goal provide for you?

3. What actions are you willing to take—starting today?

What actions are you willing to take—starting today?

4. What do you see getting in your way? Consider the external and internal factors.

What do you see getting in your way? Consider the external and internal factors.

5. What was your biggest accomplishment in the last year? Your biggest failure? The biggest risk you took? (Please give at least one sentence answer for each of these questions)

What was your biggest accomplishment in the last year? Your biggest failure? The biggest risk you took? (Please give at least one sentence answer for each of these questions)

6. What is one dream you have not yet lived or accomplished? Why haven't you/what is stopping you?

What is one dream you have not yet lived or accomplished? Why haven't you/what is stopping you?

7. What is your biggest piece of unfinished business/what is incomplete for you from the last year?

What is your biggest piece of unfinished business/what is incomplete for you from the last year?

8. How would you rate your over all level of balance in your life?

	Poor	Fair	Good	Excellent
Please choose the best fit for your overall level of balance in life.	*How would you rate your over all level of balance in your life? Please choose the best fit for your overall level of balance in life. Poor	Please choose the best fit for your overall level of balance in life. Fair	Please choose the best fit for your overall level of balance in life. Good	Please choose the best fit for your overall level of balance in life. Excellent

Other (please specify)

9. Have you ever worked with a mentor or coach? If so, were you satisfied with the outcome? What worked and what didn't?

If you haven't worked with a mentor or a coach, why haven't you?

What else would you like me to know about any of the above or anything else that we haven't covered?

Have you ever worked with a mentor or coach? If so, were you satisfied with the outcome? What worked and what didn't? If you haven't worked with a mentor or a coach, why haven't you? What else would you like me to know about any of the above or anything else that we haven't covered?

*
10. Please supply me with your contact information so we can schedule your free 1 on 1 mentoring session.

Please supply me with your contact information so we can schedule your free 1 on 1 mentoring session. Name:
City/Town:
State:
Country:
Email Address:
Phone Number:

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