Full Name: * Title/Position: * Company: * Phone (xxx-xxx-xxxx): * Website url: * E-mail Address: * Training Credentials: * Years in Profession: * Areas of Coaching * Business Performance Life Sports Relationships Fitness/Health Spiritual otherCity: * State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming --Territories-- American Samoa Federated States of Micronesia Guam Midway Islands Puerto Rico U.S. Virgin Islands Country: * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahama Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Iislands Costa Rica Cote D'ivoire (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard & McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova, Republic of Monaco Mongolia Monserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Lucia Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Pierre & Miquelon St. Vincent & the Grenadines Sudan Suriname Svalbard & Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (Great Britain) United States Minor Outlying Islands United States of America United States Virgin Islands Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Wallis & Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe Male or Female: * Male Female What % of people that inquire about your professional services are looking for a substantial change in their life? * 0% 1-25% 26-50% 51-75% 76-100% What % of people that engage in your services are doing so because they believe that you can help them facilitate a change in their life? * 0% 1-25% 26-50% 51-75% 76-100% When your clients begin a program with you, are they typically aware of the causes of their problems? * Yes No Other If you selected other in question above, please explain... When your clients begin a program with you, are they aware of their beliefs? * Yes No Other If you selected other in question above, please explain... Do your clients typically have specific goals in mind when they contract your services? * Yes No Other If you selected other in question above, please explain... In people that succeed, what changes do they make in what they believe? * In people that fail, what prevents them from doing what they know they need to do to get what they want? * What have you noticed to be the strongest catalyst in creating a moment of grand awareness, an A-ha moment? * Please provide any additional comments or positions you have on The Creation of Change Is there anything else you would like to share? Post Survey Participation (please check all that apply) * I am happy to participate, no further action is needed Send me the results of the survey when they are complete Invite me to participate in coaching discussions after the results are in I am interested in taking on additional coaching clients in the areas I outlined above
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