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* 1. First Name:

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* 2. Last Name:

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* 3. Email (please use the same email from scheduling):

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* 4. Phone Number:

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* 5. Are you more interested in changing something in your work life or in your personal life or are both equally important right now?

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* 6. What specifically are you looking to change in your life in the next 2 - 3 months?

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* 7. What is the #1 thing holding you back, right now, from being the person you want to be or reaching your goals?

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* 8. Impact, Part 1 --> Review what you wrote is holding you back. How is this obstacle impacting how you FEEL on a daily basis?

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* 9. Impact, Part 2 --> Review what you wrote is holding you back. How is this challenge impacting your relationships with friends, family, employees, or colleagues?

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* 10. Impact, Part 3 --> Review what you wrote is holding you back. How is this roadblock impacting your work performance or the amount of revenue you're generating? (Is it COSTING you money?) [Put n/a if this doesn't apply to you.]

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* 11. On a scale of 1 - 10, what is your average daily stress level?

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* 12. How much control do you have over your own environment? (For example, if it was absolutely necessary*, would you be able to have any impact on how much you sleep, when you work, your relationships, etc?)

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* 13. What have you invested—think time, energy, money—to try and fix your challenges thus far? (Books? Groups? Therapy? Programs? Retreats? Coaching? Courses? Mentors? Supplements?)

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* 14. If we decide to work together, when would you be looking to begin?

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* 15. Roughly how much time have you invested in working on your challenges?

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* 16. Roughly how much money have you invested in trying to address these challenges in the past?

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* 17. Where did you hear about us?

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* 18. This meeting with Shelly is at no cost. However, if you and Shelly decide you are a fit, she'll invite you to work with her further.

Are you in a position to invest in your personal growth right now?

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