Full Name

Your Age

Your Email

Telephone Number

Skype Address or Whatsapp

Time Zone

Which social media platform did you find me on?

What do you most want to change today?

Have you tried to change this before?

What have you attempted in the past that didn't work?

Why do you think it didn't work?

On a scale of 0-10, how important is it for you to achieve change today?

What other areas of your life do you want to change (if any)?

Thank you!
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