Personal Breakthrough Session Question Title * 1. Are you male or female? Male Female I'd rather not say Question Title * 2. What is your age? 17 years or younger 18-20 21-29 30-39 40-49 50-59 60-65 65-70 70 or older Question Title * 3. Do you own your own business (self employed) or are you an employee? Own business (self employed) Employed by someone else Question Title * 4. If you own a business, what is the gross income of the business per year? $0-$50,000 $50,001-$100,000 $100,001-$250,000 $250,001-$500,000 $500,001-$1 million $1 million-$5 million $5 million-$20 million Greater than $20 million Not applicable Question Title * 5. What are your biggest challenges right now? (Choose all that apply) Limiting beliefs Negative emotions Fear Phobia Weight loss Anxiety Smoking Depression Performance enhancement Trauma Money or success blocks Grief Confidence or self esteem Relationships Other (please specify) Question Title * 6. How long have you had this problem? 1-6 months 7-12 months 1-5 years Over 5 years Please provide details Question Title * 7. What would you like to focus on in the near future? Question Title * 8. Have you had a coach work with you previously? Yes - business Yes - personal No Question Title * 9. Contact Information Name Company Address City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * 10. Thank you for your time to complete this form.A team member will contact you very soon to arrange a time to meet up with Sharon.You may leave any additional comments in the text box below.then click on the 'Done' button to send your request. Done