Wendy Mendoza, CHPC

Your Full Name

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* 1. Your Full Name

Phone Number

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* 2. Phone Number

Address

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* 3. Address

City,State

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* 4. City,State

Email

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* 5. Email

Occupation

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* 6. Occupation

Date of Birth

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* 7. Date of Birth

Gender

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* 8. Gender

Marriage Status

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* 9. Marriage Status

What do you do for a living and why did you choose that career?

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

What are the  top 3 goals you are striving to achieve in your life and career right now?

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* 11. What are the  top 3 goals you are striving to achieve in your life and career right now?

What major stressors and challenges are you struggling with right now?

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* 12. What major stressors and challenges are you struggling with right now?

When you feel like you are most successful and happy self, what makes you feel that way?

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* 13. When you feel like you are most successful and happy self, what makes you feel that way?

What would your dream life look like if you could wave a wand and make it happen?

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* 14. What would your dream life look like if you could wave a wand and make it happen?

What has prevented you from having that dream?

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* 15. What has prevented you from having that dream?

What goal or dream have you ever given up on or failed at?

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* 16. What goal or dream have you ever given up on or failed at?

What 3 big changes would you like to make in your life this year and next year?

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* 17. What 3 big changes would you like to make in your life this year and next year?

What are you most proud of and excited about in your life right now?

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* 18. What are you most proud of and excited about in your life right now?

How would your describe your life right now?

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* 19. How would your describe your life right now?

What negative recurring thoughts, fears or behaviors would you like to overcome in order to  feel more psychologically free, confident and successful?

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* 20. What negative recurring thoughts, fears or behaviors would you like to overcome in order to  feel more psychologically free, confident and successful?

What distracts you the most from being more productive and what major projects or missions are you struggling to complete faster or more efficiently?

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* 21. What distracts you the most from being more productive and what major projects or missions are you struggling to complete faster or more efficiently?

If you were more persuasive or influential, what dream or desire would you ask others to support you in achieving?

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* 22. If you were more persuasive or influential, what dream or desire would you ask others to support you in achieving?

When do you struggle to be fully present in your day or in any of your relationships?

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* 23. When do you struggle to be fully present in your day or in any of your relationships?

How purposeful do you feel in living each day and how would you describe your purpose?

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* 24. How purposeful do you feel in living each day and how would you describe your purpose?

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