First Name

Last Name

Email Address

Phone Number

What does your business do, and who do you serve? (A brief description of your business model, products, programs, services)

Where are you right now? - Your Last 12 months of revenue (approximate): - Where you’d like to be 12 months from now:

How many years have you been in business?

What would you consider your biggest challenge/roadblock?

What do you think is the one thing that is keeping you stuck?

Where are you currently – last 12 month’s revenue?

What is your big goal or priority for the coming year?

How do you want to ‘feel’ about your business in the next year?

Any significant health issues/challenges that affect your present life?

Are you in a long-term relationship?

Do you have any children who still live with you and/or are dependent on you?

On a scale of 1 – 10 (1 being low; and 10 being let’s go today), how committed are you to making changes in your life and business that may make you feel uncomfortable?