Company Name *

Company Website *

Business & Leadership

What was your company’s revenue last year? *

How many employees and contractors do you have? *

What percentage of the company do you currently own? *

What is your core business? Describe what you do/offer/sell. *

What is your role in the company? How would you describe your leadership style? *

Challenges & Vision

What is your most pressing challenge? (In your business, leadership, and/or life.) *

Where do you want your revenue to be 12 months from now? *

What is your biggest vision for your company? *

What would a more meaningful balance between your business and life look like to you? *

What is the gap between that and where you are right now? *

Next Steps

On a scale of 1-10 (with 10 the highest), how ready and motivated are you to make meaningful change in your business and life? Please explain. *

Where could you get tripped up? *

What coaching, consulting, or leadership development have you invested in the last 5 years, if any?

How did you hear about a Rise Up Breakthrough Session with Ascend Leadership? *

Conference – Met someone from Ascend in person

Speaking Event – Heard Nadine and/or Derek Nicholson speak at a conference, podcast or other event

Impossible Freedom Quiz – I heard about this after taking the quiz

Other – (Please specify)

What else do you want us to know about you? *

Contact Information

First Name

Last Name

Title

City

State/Province *

Email *

Cell Phone *

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