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Questionnaire

Help me get to know you.

Please answer as many of the questions as possible. This will assist you in being prepared for the next step, a short phone consultation.
It will assist me in determining what will be of most value to you and that there is a good fit to work together.
I have a limited number of openings and choose to work with clients who are ready for change and determined to follow through with commitments they make during our time together on the phone. Clients who do that see results and that is what we are both looking for.

I look forward to hearing from you!

New Client Questionnaire

Name:
Email:
Phone#:
Country:
Time Zone:

What type of personal development have you done in the past (Life Coach, personal development seminars, workshops, books, reading materials etc) or is this area new to you?

If yes, was there anything in particular that you liked?

What didn’t you like?

What are your expectations? What do you plan to accomplish?

Is the idea of thinking in terms of energy and frequencies new to you?

If this is not new to you, do you have something you already work with and consider it to be useful in removing blocks or memories of previous bad experiences?

Have you ever worked with visualization?

Can you close your eyes and mentally see an image?

If not, can you close your eyes and remember the last meal you had?

Do you consider yourself to be an open minded person with a desire to learn new things?

You must assess where you are now and where you want to be. How many of these questions can you answer clearly? Without creating stress over it, please answer all you can.

What does success mean to you?

If you were to close your eyes and think of living a fulfilling life, or a perfect day in that life, what would that look like? Does a picture come to mind? What would you be doing?

What feelings do you associate with the picture? (Happiness, excitement, relief etc.)

What are some things that would have to be in place for you to experience days like that? (Changes in finances, relationships,career, weight, health etc.)

Do you see the potential for attaining the life you want to grow out of the way you are living now or would it take radical changes and a departure from the way you are living now?

What are your predominant beliefs about your ability to attain the life of your dreams?

Do you NOT KNOW where you want to be but know it’s not where you are now?

Do you KNOW where you want to be but not HOW to get there?

Are you willing to do what it takes? Is the desire or passion strong enough?

What is the first action step in working toward a life filled with days like you visualized? What would you do to feel like you had gotten started? What would the first baby steps be?

Do you have anything you would like to add?

Assuming you feel confident that there is a good fit to work together and that you will see results, what is the greatest influence on your decision involving the investment you are willing to make to work with me to accelerate change in your life?

Effectiveness and speed? (I will cover all the options)
A tight budget? (I will cover programs developed to help people who are serious yet on a tight budget.)
I am going to be forthright in saying that it is impossible to spend personal time with everyone who visits my website or wants information.I am looking for serious clients who are ready to change their lives. There has always been and continues to be an investment that I make in developing my skills and there is an investment for you.

My newsletters and blog will offer free information and I welcome anyone who is interested in learning more to subscribe and take advantage of those resources. I am hoping they will be of great value to anyone who spends time with them.

After you read this questionnaire, if you have questions, please email me at peaceofsuccess@gmail.com or call my office at 615-884-3731

After I receive your questionnaire, if there seems to be a good fit, we will schedule a 15 minute phone consultation.

I look forward to working with you. Thank you!

Teri Rose
Peace of Success
2817 West End Ave #125-294
Nashville, TN 37203-1453
615-884-3731

Email: peaceofsuccess@gmail.com
Return to PeaceOfSuccess.com

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