Full Name
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Email
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Phone
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What's holding you back from the results you want?
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Lack of Time
Lack of Motivation
Lack of Willpower and Discipline
Lack of Knowledge
Lack of Accountability
Cravings And Portion Control
Other
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On a scale from 1-5 (1 Horrible 5 Beyond Exceptional) where would you rank your BODY
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1 - Horrible
2
3 - Average
4
5 - Beyond Exceptional
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Why are you interested in working one-on-one with Pardha ?
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On a scale from 1-5 how motivated are you to experience these changes in your life?
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1 - Not Motivated
2
3 - Interested but not committed
4
5 - Extremely Motivated
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If you were able to find a way to lose your desired amount of weight and reach your health goals through our online nutritional & fitness coaching program, would you be willing (and able) to invest in getting the help necessary to get there?
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Yes - I Have the cash flow to invest in myself.
Yes - I may or may not have the cash flow but I'm resourceful or have access to credit
No - My cash flow is month to month and I have no access to credit
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