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INSTRUCTIONS -
On a scale of 1 (Not Agree at all) to 10 (Totally Agree), rate the following statements:
*
Indicates required field
Email
*
Name
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First
Last
I am ready to create more balance in my life
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Blank
1 (Not at all agree)
2
3
4
5 (Somewhat agree)
6
7
8
9
10 (Totally agree)
I am ready to improve my personal and professional relationships
*
Blank
1 (Not at all agree)
2
3
4
5 (Somewhat agree)
6
7
8
9
10 (Totally agree)
I am ready to make real POSITIVE CHANGES in my life
*
Blank
1 (Not at all agree)
2
3
4
5 (Somewhat agree)
6
7
8
9
10 (Totally Agree)
I am ready and willing to OVERCOME self-limiting behavior
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Blank
1 (Not at all agree)
2
3
4
5 (Somewhat agree)
6
7
8
9
10 (Totally agree)
I am ready to create and take ACTION to achieve my GOALS
*
Blank
1 (Not at all agree)
2
3
4
5 (Somewhat agree)
6
7
8
9
10 (Totally agree)
I am ready to achieve a sense of fulfillment at work and in life
*
Blank
1 (Not at all agree)
2
3
4
5 (Somewhat agree)
6
7
8
9
10 (Totally agree)
I would like to work less and make more
*
Blank
1 (Not at all agree)
2
3
4
5 (Somewhat agree)
6
7
8
9
10 (Totally agree)
I can benefit from someone who will help me stay on track
*
Blank
1 (Not at all agree)
2
3
4
5 (Somewhat agree)
6
7
8
9
10 (Totally agree)
Submit
PVR Coaching & Consulting
24 Camp Avenue #4990
Stamford, CT 06907
+1 267 218 6004
[email protected]
Qualified Administrator
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