Name
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First Name
Last Name
Email
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Phone
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Country
(###)
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Birthday DD/MM/YYYY
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What is the area(s) of your life that needs the most attention now and why?
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What are the biggest obstacles you're facing when it comes to achieving your goals?
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What have you already tried to do to overcome your obstacles?
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What do you do for a living? What is your favorite part about your job?
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Holistic Health Check In
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I feel good about my DIET, EXERCISE, and SLEEP routines.
I feel satisfied with the quality of the RELATIONSHIPS in my life - family, friends, partner, community, etc.
I feel passionate about my CAREER and my contribution to the betterment of the world.
I am connected to my SPIRITUALITY and higher power.
I am happy with my level of FINANCIAL abundance and security.
What are the major stressors in your life currently? And, how do you manage your stress?
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On average, how many hours of sleep do you get per night?
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5 hours or less
6-8 hours
8 hours or more
On average, how many times per week do you engage in some form of physical activity?
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Everyday
3-5 days per week
Twice per week
Never
On average, how many times per week do you meditate?
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Everyday
A few times per week
I have meditated but don't practice consistently
I've never meditated
When you think about making changes in your life, which part excites you the most?
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Are you ready to commit your time, energy, and finances to your health and personal development?
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YES DEFINITELY
NOT SURE
Have you ever worked with a coach, therapist, or healer? If so, which type?
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Any last thoughts, comments, questions, or health concerns you'd like to share?
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