Please complete this form- We are excited to learn how we can assist with improving your performance

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* 1. Your Contact Information

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* 2. Your Age

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* 3. Your Marital Status

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* 4. Your Occupation

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* 5. Rate yourself on a scale of 1-10 in each of the following areas. 1 being, that you have NOT made any progress in this area and 10 being that you are RIGHT where you think you should be by this stage in your life?

  1 2 3 4 5 6 7 8 9 10
Health
Finance
Career
Relationships
Emotions
Time Management

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* 6. Pick 3 of the above categories that you want to change and/or improve.
In the space below, explain what would have to happen in order to take each of these 3 areas to a level “10” experience?

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* 7. What is the PAY OFF for achieving these goals? How is your new life going to be different? What is the upside or the reward for following through on these goals?

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* 8. What beliefs, fears and/or patterns of behaviors have prevented you from already achieving these goals? 

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* 9. What is the COST or the Negative Consequences for not following through? What is your life going to be like if you continue to buy into your excuses, patterns and fears?

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* 10. Why are you a good candidate for our coaching and how do you think you will be able to benefit from a coaching program like this?

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* 11. What type of coaching are you looking for?

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* 12. How did you learn about Jairek and/or coaching?

Please click "DONE" below to submit your answers.

Note from JR: Congrats on taking the first step towards seeing Rapid Results in your life and business and THANK YOU for taking time to fill out this client questionnaire! After reviewing your answers, one of our best performance coaches will reach out to set up a day & time for your complimentary discovery coaching session to deliver amazing results.

Have an amazing day!

To your success,
Jairek Robbins

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