Background

Thanks! Please take a few minutes to give me some background that we can talk about.

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1. Name (Required.)

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2. Email Address (Required.)

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3. Time Zone or City you live in (Required.)

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4. What is your gender?

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5. Age?

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6. I have a REAL PRIORITY (goal) I'd like to achieve within the next year

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7. Please send me the PDF (P.E.T) Personal Evaluation Toolkit (FREE) as soon as possible.

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8. I'm very interested in the 28 Day Breakthrough Course and / or your group coaching!

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9. The following questions relate to the 28 Day Breakthrough Course (these are optional)

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10. On a Scale of 1 - 10 My Belief that I can achieve my goal is...

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11. On a Scale of 1 - 10 My Commitment Level to Achieving this goal is...

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12. My Goal is...

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13. What has been the greatest highlight of your life so far?

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14. What is one of the lowest points of your life (optional- do not have to complete)

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15. What is your greatest talent/ability (from a professional/value standpoint)

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16. What would a best friend or parent brag about when they were talking about you

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17. If I achieve my goal within the next year I will feel...

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18. If I do not achieve my goal in the next year I will feel....

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19. My desire for coaching is more directed toward

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20. I heard about The Habit Factor via

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21. List 3 of your best habits

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22. My 3 Worst habits are

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23. My Annual Income (range)

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24. I am able to use my cash/savings and do not have to pay for coaching using debt (credit card)

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25. I view coaching for self improvement/goal achievement as a...

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26. I am currently using The Habit Factor app (ios or android) and tracking my habits

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27. Phone Number or Skype Handle (preferred)

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28. Best Time for calls

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