Name:: *

Instagram handle:

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Email:: *

Age?: *

Could you please explain what would you like to achieve in the next 3 - 6 months?: *

What do you feel is preventing you from achieving you goal on your own?: *

If it was certain that you could reach your goal with my support are you prepared to invest in yourself?: *

YESNO

Is there anything else you think I should Know about you?: *

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