Breakthrough Session Form
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Full Name
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Email
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Phone
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What are your Pronouns?
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Are you over 30 years of age?
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Yes
No
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Are you from Yuma, AZ?
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Yes
No
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What Health & Wellness Solutions Are You Interested In? Select all that apply.
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Health Coaching
Nutrition Coaching
Online Personal Training
Energy Healing
Metaphysical Coaching
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Tell me more about your story, your struggles, and why you feel you need coaching.
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What's your monthly health budget?
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Under $100 per month
Up to $400 per month
Up to $800 per month
Over $900 per month
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Are you ready, able, and willing to make the changes you are looking for?
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Yes
No
Maybe
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How would you like to meet for our call?
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Zoom Video Call
Phone Call
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How did you hear about me?
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Google
Instagram
Facebook
Word of Mouth
Other
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Submit & Book Appointment
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