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* 1. Full Name

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* 2. Email Address

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* 3. What do you desire to be, feel, experience and think?

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* 4. Describe you on an ideal day, one year from now. What are you doing and where?

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* 5. What is holding you back from achieving your goals?

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* 6. What are you hoping to get from this program?

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* 7. Why are you looking for change now? How committed are you?

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