Part 1:

First Name

Last Name

Email *

Phone *

Age

City / Time Zone

What Is Your Relationship Status

If Applicable:

Partner’s First Name

Partner’s Last Name

Partners Email

Partners Phone

Partners Age

Part 2:

What is not working in your life right now? Where are you out of alignment, frustrated, disconnected, or stuck?

Where / how have you already tried to solve this, and why hasn’t it worked?

If nothing changes in the next 1–2 years, what will it cost you? (Your relationship, your family, your peace, your direction, your sense of self…)

Part 3:

If this work goes exactly right… what does your life actually look like? Be specific — how you feel, how you show up, how your relationships operate, what changes tangibly.

Why is that life important to you?

Part 4:

What level of ownership are you willing to take for your life right now? (Be honest — are you fully in, or still testing the waters?)

Why now? What has shifted that makes this the moment for change?

Are you willing to be challenged, told the truth, and held to a higher standard than you’re currently living? (Yes / No — explain)

Part 5:

How did you hear about us?

Part 6:

Level of support: Which level of support are you ready to step into?

*Select the option that reflects both your desire for transformation and your current level of investment readiness.