Empower Yourself to Excel - Wellness Coaching

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Wellness Coaching | Weight Management | Sports Performance | Products & Services

Are You Ready to Change?

*Your Name:
Address:
City:
State:
Zip:
*Phone Number:
Mobile Number:
*Email Address:
Birthdate:
Your Age:
Best Time to Contact:
What is the Goal or Behavior you desire to change?
Please contact me to schedule a complimentary "jump start" coaching session:
Describe the vision you have for yourself when this goal is achieved. Describe what this vision looks like to you and the benefits of achieving the goal.
What might get in the way of reaching this goal or ideal vision?
Which Statement best describes you with the above goal or behaviour to change?
I am not working on that goal and I am not even considering it. I have worked on the goal before and am thinking about getting started again I hesitate to work on that goal because I failed before and I am tired of trying I would like to work on this goal but I do not know of an effective program I am planning to take action to achieve this goal and I do not have a plan of action I am planning to take action to achieve this goal and I do have a plan of action I am working on this goal but occasionally I get stuck and need some help I am working on this goal and I have been successful for 6 months or longer
On a scale from 1 to 10, How motivated are you to make this change? (0 = Not Motivated; 10 = 100% Motivated)
On a scale from 1 to 10, how committed are you to taking action? (0 = Not Committed; 10 = 100% Committed)
On a scale from 1 to 10, how much confidence do you have in making your wellness vision become a reality?
(0 = Not Committed; 10 = 100% Committed)
Please contact me to schedule a complimentary “jump start” coaching session :
Please put me with more information on how to achieve my goal:
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Excel Performance Enhancement Services
Scottsdale, Arizona

coach@empoweryourselftoexcel.com · (480) 773.5497