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* 1. Your Full Name

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* 2. Phone Number

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* 3. Address

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* 4. Email

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* 5. What is your gender?

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* 6. What is your age?

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* 7. Occupation

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* 8. Please rate yourself in the following areas of your life on a scale of 1 (lowest) to 10 (highest)

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* 9. Clarity: Do you feel you are clear about who you are, your purpose, and the direction you want to go in life? (scale of 1-10)

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* 10. Energy: Do you consistently have enough mental and physical energy needed to excel, accomplish your goals, and feel motivated and happy? (scale of 1-10)

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* 11. Courage: Do you take action and consistently express who you truly are and what you truly think, need, and desire with the world? (scale of 1-10)

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* 12. Productivity: Are you consistently focused and effective, and are you good at minimizing distractions and maintaining priorities? (scale of 1-10)

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* 13. Influence: Do you feel you have the social influence with your family, friends, and team needed to accomplish your goals? (scale 1-10)

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* 14. What do you do for a living, and why did you choose that career?

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* 15. What 3 big changes would you like to make in your life in the next 12 months?

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* 16. Why would you like to work with a high performance coach?

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