Tell Me About Yourself

This 5 Minute Background Form is Required

Your appointment is not confirmed until we receive this. If we do not
receive your completed background information within 12 hours, we will cancel the appointment.
Please do that right now!

Complete this form now!

Please fill out this required application as completely and as accurately as possible.
We get a LOT of applications for the available calendar slots and can only take the candidates who are the very best fit for the high level coaching environment in BREAKTHROUGH.

Application must be completed within 12 hours or your session will be cancelled.*

*If you are rescheduling an appointment and have already filled out the application, you may skip this step.

First Name *

Last Name *

Email *

Age *

Relationship Status *

Married/Committed Single Divorced

# of Children and their Ages *

Check all that apply *

*If business owner, briefly describe business and share website

What is your Facebook Profile Name

What is your LinkedIn Profile Name

For each category, indicate how SATISFIED you are today:

Professional Success *

Financial Success *

Relationships *

Personal Well Being *

How I manage my time *

Pursuing my dreams *

My plans for the future *

What specific changes do you want to make through coaching to feel better about your answers above? Please list and explain. *

How willing and able are you right now to invest in coaching as a conduit to the goals you've described here? *

I HAVE financial resources available for coaching.

I could access financial resources to invest in coaching with a little creativity.

I have NO financial resources available for coaching.

Anything else you'd like to share before we meet?

I am a person with integrity. If my application is accepted I will be available to answer my call at my scheduled appointment time. If I need to reschedule I will do so with at least 24 hours notice. *