First Name
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Why are you interested in working one-on-one with XYZ company ?
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On a scale from 1-5 how motivated are you to experience these changes in your life?
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Please Select
1 - Not Motivated
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3 - Interested but not committed
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5 - Extremely Motivated
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If you were able to find a way to lose your desired amount of weight and reach your health goals through our online nutritional and fitness coaching program, would you be willing— and able —to invest in the help necessary to get there?
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Please Select
Yes - I have the cash flow to invest in myself.
Yes - I may or may not have the cash flow, but I'm resourceful or have access to credit.
No, my cash flow is month-to-month, and I have no access to credit.
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What's holding you back from the results you want?
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Plesae Select
Lack of Time
Lack of Motivation
Lack of Willpower and Discipline
Lack of Knowledge
Lack of Accountability
Cravings And Portion Control
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Could you share the specific challenges you're facing and how long they've been affecting you?
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On a scale from 1-5 (1 Horrible 5 Beyond Exceptional) where would you rank your BODY ?
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Please Select
1 - Horrible
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3 - Average
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5 - Beyond Exceptional
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