Last Name
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First Name
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Email
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Phone
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What area of your life are you most focused on improving right now?
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Career and Success
Health and Wellness
Relationships and Connection
Personal Growth and Spirituality
How would you describe your current state of mind?
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Energized and Focused
Stressed and Overwhelmed
Balanced and Content
Curious and Seeking
Which statement resonates with you the most?
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“I want to achieve my goals and dreams.”
“I seek inner peace and well-being.”
“I value deep connections with others.”
“I’m on a journey of self-discovery.”
How do you currently prioritize self-care?
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I make it a daily priority
I try but struggle to find time
It’s important, but I often neglect it
I haven’t thought much about it
Which word best describes your desired state of being?
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Successful
Balanced
Connected
Enlightened