Heal Your Soul Free Your body Form

Uplevel Your Potential Masterclass by Valerie Shakti Bottazzi

HEAL YOUR SOUL FREE YOUR BODY APPLICATION

Today's Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Email*
Phone Number*
Date of Birth*
Date Format: MM slash DD slash YYYY
Time of Birth (if you know it)
: HH
MM
Location of your Birth*
City State / Province / Region Country
Rate each of the following from 1 to 5. Note: 1 being “hardly ever” and 5 being “you can’t imagine this could possibly be any better”
I feel great/confident about myself*
I am at a weight I feel comfortable with*
I feel centered, clear, and on purpose, in my life and work*
I am connected to my emotions, I am clear about what I feel when I feel it*
I have the impact I want to have on the world*
I am taking action on the dreams and visions that are important to me*
Upleveling Your Life
Which of the areas above do you most want to change over the next 6-12 months?*
Are you living your soulful purpose? Describe where are you in your path.*
Describe what your life and health would be like if there was nothing limiting you or holding you back?*
Assuming all human beings have some way of holding back or sabotaging our lives which are your favorite methods?*
Which of these represent you more, feel free to add your own. Procrastination, Indecisiveness, Arrogance, Acting as a lone ranger, Tolerating, Not saying YES or NO, Controlling life or people, Following secondary goals that won't ultimately make me happy, Not telling the absolute truth (even to myself).
What would you get from coaching that would be most valuable to you? (choose up to 3)*
Challenge Accountability Focus Support Inspiration Direction Sounding Board Ideas / Strategies
If you had a magic wand, what would your life look like ONE year from now?*
List 3 adjectives that describe you at your best.*
List 3 adjectives that describe you at your worst.*
Heal Your Soul Free Your Body is a 10 month journey that requires your commitment to yourself & the group. Are you ready to commit time & money, be vulnerable and coachable ready to heal & willing to embrace the process?*
- Yes Highly
- Reasonable
- It's a strech
- I am trouble
- No
Which of these best describes you?*
Is there anything else you would like us to know?*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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HEAL YOUR SOUL FREE YOUR BODY APPLICATION

Rate each of the following from 1 to 5. Note: 1 being “hardly ever” and 5 being “you can’t imagine this could possibly be any better”

Upleveling Your Life