Name
              
                * 
              
             
          
                
                
                  
                     
                    First Name 
                   
                
                
                  
                     
                    Last Name 
                   
                
               
            
            
            
            
            
            
        
          
          
            
            
            
            
            
              
                
            
              Email
              
                * 
              
             
          
                
                 
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              Phone
              
                * 
              
             
          
                
                
                
                  
                     
                    (###) 
                   
                
                
                  
                     
                    ### 
                   
                
                
                  
                     
                    #### 
                   
                
               
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              Date
              
                * 
              
             
          
                
                
                  
                     
                    MM 
                   
                
                
                  
                     
                    DD 
                   
                
                
                  
                     
                    YYYY 
                   
                
               
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How would you rate your current physical health?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How satisfied are you with your current level of physical activity or fitness?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How would you rate your sleep quality and overall energy levels?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How would you rate your nutrition?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How would you rate your current mental and emotional well-being?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How well do you feel you manage stress and cope with challenges in your life?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How satisfied are you with your current work-life balance?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How would you rate your connection to your spiritual practices or beliefs?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How often do you engage in activities that nurture your spirit (e.g. meditation, prayer, reflection)?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How aligned do you feel with your higher purpose or sense of meaning in life?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How would you rate your current financial stability or security?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How satisfied are you with your ability to manage your personal finances (budgeting, saving, investing)?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How would you rate your financial goals and the progress you've made towards achieving them?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How effectively do you feel you lead your team (if applicable)?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How well do you think your team members collaborate and communicate with one another?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How well do you feel you provide direction, motivation, accountability, and support for your team?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How would you rate the overall systems of your business (systems, processes, workflows)?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How effective do you feel you are at managing your time and priorities as a business owner?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How satisfied are you with the current level of growth and progress your business is experiencing?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
              
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How confident are you in your marketing strategies and campaigns?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How well do you feel your business is represented online and through digital marketing?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10 
                  
                   
                 
              
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How well do you feel you are attracting your ideal patients?
              
                * 
              
             
          
                
                
                
                  
                    1 
                  
                    2 
                  
                    3 
                  
                    4 
                  
                    5 
                  
                    6 
                  
                    7 
                  
                    8 
                  
                    9 
                  
                    10