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* 1. Check each statement that you relate to

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* 2. On a scale from 1 (not at all relevant) to 7 (extremely relevant), please rate how relevant each factor is at holding you back in your life. By relevance, we mean how much impact does this factor have on your goals.

  1-Not at all relevant 2 3 4 5 6 7-Extremely relevant
Time
Fear
Finances
Health
Your Partner
Self Esteem
Energy level

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* 3. If you had no limitations, what would be your biggest goal? A goal for you personally.

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* 4. What is your age range?

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* 5. Highest level of education completed

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* 6. Employment Status

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* 7. Relationship Status

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* 8. How many children do you have?

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* 9. All applicable age ranges of your children?

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* 10. Check all that apply to you.

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