First Name
Last Name
Date of birth
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How do you usually feel when you try to build new habits?
A. Hopeful, but unsure where to start
B. Motivated at first, then I slowly fall off
C. I understand habits well, but staying consistent is hard
D. I’m serious about habits and want deeper support and refinement
When motivation fades, what tends to happen?
A. I stop completely and feel discouraged
B. I try again later and repeat the cycle
C. I keep going, but inconsistently
D. I adjust and want guidance to stay on track
How much structure feels supportive to you right now?
A. Very light — I just want something simple
B. Some structure — but not overwhelming
C. Clear structure with accountability
D. Strong structure with guidance and feedback
What’s your biggest struggle with habits right now?
A. Knowing where to begin
B. Staying consistent over time
C. Recovering after missed days
D. Refining habits so they fit my lifestyle long-term
How do you feel about accountability?
A. I’m new to it, but open
B. I think it would help me stay consistent
C. I know I need it to avoid falling off
D. I want ongoing accountability and support
How much guidance do you want while building habits?
A. Basic guidance and simple tools
B. Clear steps and gentle check-ins
C. Regular feedback and progress reviews
D. Personalized guidance with deeper support
Which statement feels most true for you?
A. “I want a calm reset and a place to start.”
B. “I’ve tried before and want more support this time.”
C. “I want consistency to finally stick.”
D. “I’m ready to commit and optimize my habits.”
What feels most important to you right now?
A. Clarity and simplicity
B. Momentum and encouragement
C. Accountability and structure
D. Mastery and long-term growth