Reach you Goals with Les Schmidt

Help me get to know you by answering the questions below. When you are finished, hit the submit button at the bottom of the form. You will then be contacted personally by Les Schmidt for your FREE consultation!

Name:
Street Address:
City, State, ZIP
Phone Number:
Email Address:
Current Occupation / Job Title:
Partner's name:
Your Current Age:
(PLEASE CHECK the things that you want to improve in your life, have tried to improve, or HAVE improved)	Gain Self-esteem Gain confidence Change my career/occupation Improve my relationships Have better health/wellness Increase my motivation Have more money Increase my salary Get out of debt Feel less stress Get in good physical shape Have more time to do what I want Get more done in less time (be more productive) Create more success in my life Get a new job Start my own business
Do you currently have a coach?	YES NO
Have you ever worked with a coach?	YES NO
Do you work too much?	YES NO
Do you work at a job you don’t like?	YES NO
Do you have the money you want/need?	YES NO
Are you missing key relationships?	YES NO
Do you feel stressed/worried?	YES NO
Are you focused?	YES NO
Are you missing balance?	YES NO
Do you have time for hobbies?	YES NO
Are you focused on problems/challenges?	YES NO
Does it seem you never get what you want?	YES NO
Are you procrastinating?	YES NO
Are you living your mission?	YES NO
Visions & Goals	Obtain career satisfaction Create more time Have better relationships Have life/work balance Stop procrastinating Have more energy Reduce my stress Have less fear Have high self-esteem Increase my health/wellness Gain confidence Live my life’s mission Increase my income

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