First Name *

Last Name *

Email *

Phone *

Website/URL

Please list your main social media handles *

City *

Country *

Country

How do you know about Pauline?

Referral

Heard You Speak

Social Media

Read Your Book

Purchased Your Product

Other

If Other - Please specify.

How old are you? *

How old do you feel? *

What are your Professional Goals? *

What is your profession? *

Are you happy in your current profession? *

Yes

No

Do you have a Grand Dream? Would you care to share it? *

What are your darkest fears? *

Why would you like to be coached / mentored by Pauline Nguyen? *

List any relevant assessments you have recently had that could be provided so that Pauline can understand you better.

Have you ever had a coach / mentor before? *

Yes

No

Who was your coach / coaches? In what areas were you coached?

In order of importance to you, order the following human needs from 1-6. Significance, Certainty, Variety, Growth, Love & Connection, Contribution *

1 - Most important
2
3
4
5
6 - Least important

In order of importance, which best describes you? Order the following traits from 1-4. Determined and Driven, Spontaneous and Carefree, Skeptical and Analytical, Always put the needs of others first

1 - Most important
2
3
4 - Least important

What do you want to experience in LIFE? *

How do you want to GROW? *

What do you want to CONTRIBUTE? *

Who is the person you dream of becoming? What does this new version of feel like? *

What are your greatest desires? *

What do you think is holding you back ? *

Do you experience pain, dis-ease or disease? *

Yes

No

Is it emotional, mental, physical or spiritual?

Tell me more about your pain.

If other, please explain.

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