Section 1 – Contact Information Name Email Phone Section 2 – Participant Information Gender MaleFemaleOther Age Range —Please choose an option—18–2526–3536–5051+ How did you hear about us? —Please choose an option—Referred by friendSocial MediaEventOther Section 3 – Personal Empowerment Snapshot Mind—Please choose an option—WeakAverageStrongOptimal Body—Please choose an option—WeakAverageStrongOptimal Spirit—Please choose an option—WeakAverageStrongOptimal Relationships—Please choose an option—WeakAverageStrongOptimal Finances—Please choose an option—WeakAverageStrongOptimal Career—Please choose an option—WeakAverageStrongOptimal Time Management—Please choose an option—WeakAverageStrongOptimal Section 4 – Passion • Purpose • Possibility Alignment I’m clear about my passionI’m exploring my purposeI’m uncertain about my possibilitiesI’m ready to activate all 3 now Section 5 – Current Challenges ProcrastinationImbalanceFear of failureDisorganizationPoor disciplineTime management issuesToxic relationshipsLow motivation Section 6 – Commitment & Readiness 1–3 Minimal Readiness4–6 Moderate7–8 Strong9–10 Fully Activated Section 7 – Coach Follow-Up Schedule initial sessionAssign PERP assessmentEnroll in Get Activated Community Signature Closing Question Would you like assistance or a personal empowerment coach to help eradicate the organized chaos and activate your true identity? YesNoNot sure
