All information is confidential and private.

When we have a desire to change an area of life and/or become a better version of ourselves, it is

important to identify what we want to change. Consider the level of importance for each of the areas of your life. If there are people you know who may have an interest in Lifestyle change and or support your change, please write their names.

Where do you see yourself on a scale from 1 (not important) to 10 (very important)?

Achieving Financial Goals/Secondary Income

Having more time to Enjoy Life/Develop my Purpose

Achieving Personal Goals

Being my own Boss/Self-Employed

Being Healthy/Overall Wellness

Eating Healthy/Weight Management

Being Mentored/Coached

Investing Time into Others

If anyone comes to mind regarding the above topics, please list their name(s) here.

Check the top 5, positive characteristics you possess:

Ambitious

Coachable

Dependable

Disciplined

Entrepreneurial

Friendly/Fun

Goal Oriented

Health Conscious

Leader

Love Helping Others

Open Minded

Out of the Box Thinker

Self-Motivated

Team Player

Well Connected

If I could change one thing about my job and/or current lifestyle what would that be?

How much extra money per month would make a difference for you NOW?

Even though my schedule is very busy I would like more...

Is there any reason you wouldn't be willing to invest 30 minutes of your time to learn more?

Name:

Best Time to Reach You:

Phone:

Email:

Thank you for submitting your lifestyle survey!

We look forward to connecting with you.

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Phone: 727-492-8212

Address: PO Box 8061
Fleming Island, FL 32006

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