BREAKTHROUGH SESSION APPLICATION
Welcome!
Please take a few moments to
answer these 7 questions.
1. What is your first name?
2. What is your email address?
3. What state do you live in?
Select one...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
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New Jersey
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New York
North Carolina
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
I live outside of the United States
4. What do you want to change in regards to your health? What are you struggling with? Why is it important for you to change this?
5. What are your health goals? What are you hoping to accomplish while working with me? Where would you like to see yourself in a few months?
6. How important is it for you to achieve your health goals?
Select one...
0 - Not important
1
2
3
4
5 - Somewhat important
6
7
8
9
10 - Extremely important
7. If you were offered a program that you believed would help you achieve your health goals, would you be willing to invest in yourself?
Select one...
Yes!
No
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