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Name*
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Best Email (please use the same as you gave for the appointment booking)*
Phone Number*
✓ Valid number ✕ Invalid number
What’s your occupation?*
Your Business Website (if you don't have one, leave blank')
How did you hear about MOVE THINK SMILE (Adam Von Ins & Eléa Faucheron)?*
- Webinar / Workshop
- Facebook
- Email
- Book
- Podcast
- Referral
- Website
- Youtube
- Google
- Other
What symptoms are you experiencing?*
- Fatigue
- Productivity Loss
- Weight Gain
- Headaches
- Poor Sleep
- Stomach Problems
- High Blood pressure
- Despair
- Overwhelm
- Anger
- Anxiety
- Depression
- Brain Fog
- Burnout
- Suicidal Thoughts
- Other
How are these affecting your professional success?*
How are these affecting your personal life?*
How would increasing your energy & career performance change your life?*
What have you tried to increase your energy and fuel your career? (please include all stress management & coping mechanisms)*
If someone advised me to invest in my health & performance above all else, I would:*
- Know it's what any serious professional does to increase their energy & fuel their career.
- With a proven system I would do it because I'm serious about getting my energy back.
- Say NO, because it doesn’t seem like a good strategy to me when there is so much to get done.
Currently, I . . .*
- Have the financial resources to invest in my health, energy & career.
- Have access to financial resources to invest in my health & career.
- Really want more energy, but am unable to invest in my health & career.
Do you promise to show up for your scheduled appointment ON TIME and DISTRACTION FREE? Please confirm by typing "Yes I will" below.**
Finally, on a scale of 1 to Bruce Lee, how awesome are you?*
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