Your First and Last Name
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First Name
Last Name
Your Email
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What SCORE out of 10 would you give for how SATISFIED you are with your overall wellness (nutrition, movement, sleep, stress management, connectedness -to self and other and environment)?:
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Give a SCORE out of 10 for how ENERGETIC you feel in your life:
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Give a SCORE out of 10 for how EMPOWERED / CONFIDENT you feel in your life:
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Give a SCORE out of 10 for how overwhelmed, BUSY or stressed you usually feel:
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You BELIEVE in yourself and TRUST your INTUITION to guide you in making positive, sustainable changes in your health & wellness:
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Yes
No
Maybe
What is your FAVORITE thing about your health & wellness in life at the moment?:
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What could be IMPROVED about your health & wellness at the moment?:
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Thinking about coaching, I am looking:
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Check all the apply
If other was selected above, what else are you looking for?:
I am ready to take ACTION, and make positive, lasting changes for my health & wellness:
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Yes
No
Maybe
