Client Survey

Your First Name*

Your Last Name*

Your Email*

Main Issue: What is your main complaint, issue or challenge?*

How long have you been aware of this?*

What have you actively done for resolution?*

What is this costing you (In money, lost income, strained relationships, lost opportunities, impaired health, etc.)?*

Your results so far (How much time and money have you spent on this so far and what results have you gotten?)?*

What would it be worth (How would it feel and what would it be worth to you to resolve this issue within 30, 60, or 90 days?)?*

How ready are you?*

Contact Information (please enter your phone number or Skype name)*

Your time zone*