Application Form
Name
*
First Name
Last Name
Instagram handel
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Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Please select your Time Zone
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Where did you hear about me?
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Instagram
Facebook
Word of mouth
Natural Therapies Pages
Why are you are reaching out?
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What are you hoping to get out of our call?
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What results would you like to achieve?
What would you like to accomplish in 12 weeks?
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What is your #1 goal that once solved would make life 10x better?
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Which of the following best fits your goals
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Anxiety & Emotional Regulation
Post Relationship Healing
Childhood Trauma Healing
Other
What would you like to see happen after 12 weeks with Adele?
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Overcome Panic Attacks
Gain confidence and self esteem
Achieve Emotional Regulation
Heal Post Relationship
Other
Roadblocks
What limitations you currently facing?
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What are the top 3 things keeping you from reaching your goal?
*
A FULL BREAKTHROUGH focuses on Emotional Regulation, Resilience, Accountability and Discipline as core principles, which do you struggle with most?
Emotional Regulation
Resilience
Accountability
Discipline
What would you like my help with most? What do you want me to help you with?
Qualifier
On a scale of 1 to 10 how important is solving this problem to you right now?
Are you willing to make a 4 figure investment to solve this problem?
Yes
No
Need Payment Plan
Are you willing to do whatever it takes to this problem?
Yes
No
Submit
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