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* 1. What kind of business or professional practice are you in? What is your role or position?

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* 2. What kinds of services or products do you offer? If just starting your business, please say so, and add what would you like to offer.

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* 3. What are your biggest problems and challenges in your practice, your business, or your work? Please check your top three or four difficulties.

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* 4. What inner issues do you have that may be slowing you down, or even stopping you from achieving the professional success and personal fulfillment you know you are capable of?

Remember EVERYONE has them, and your answers are entirely confidential.

Your inner issues could be any of these, or something else entirely:

Being Overwhelmed, Unfocused, and/or Disorganized
Lacking the Right Mindset, Self-Esteem or Positive Attitude
Anxiety or Fear
Lacking the Inspiration and Passion---Getting Off My Butt
Depression or Addictive Behavior
Feeling Hopeless or Lost Inside, and a Lack of Direction
Procrastination Issues
Other

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* 5. On a scale of 1-10, 10 being highest, how motivated are you to overcome your challenges and achieve your Vision, Goals, and Objectives in the next 6-12 months?

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* 6. How would you most prefer to learn the solutions to your problems, transform your challenges, and go freely toward your goals?

List one or two, or three at the most:

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* 7. What is your preferred method for receiving information about developing your practice, building your business, and/or resolving core issues in the way of your success?

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* 8. With expert coaching, what do you think your income or happiness levels could be in this next year with help in visioning, stratgic planning, marketing, or transforming your issues?

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* 9. What was your approximate business revenue over the last 12 months? This is completely confidential.

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* 10. Please list your contact information below if you would like to receive my ebook RECREATE YOUR LIFE with my compliments, and/or be entered in the contest to win a Free One Hour Coaching Session with me ($200 value.)

When you do, I will email you the link for my ebook and enter you into the contest. Thank you.

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