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First Name *

Last Name *

Email *

Phone Number *

What have you done looking back others might view as impossible?

(iE: Remain married to the same beautiful mate - raise an impossible child to functioning adult - run a marathon - achieve a hole in one in golf or have a single digit handicap - get a pilots license after fifty or learn a third language - achieve success in second career. *Please explain your impossible achievement above.*

What is your physical, mental and emotional state after the stroke in your own words?

Please write about your support team – how they feel about your stroke and how well do you receive their help?

In your words, please define diligence. What kinds of things in your life that you do consistently?

How long have you been struggling with your stroke?

Less than one year

One to two years

Two to five years

Five to ten years

Over ten years

What do you feel you most need our help with right now?

If chosen for the program

Do you have funds to invest in your health.

Do you ability to access funds for coaching

I don’t have funds for coaching.

On a scale between one and ten

1 - Not very serious about improving

10 - I will do whatever it takes to improve my life

In the multiple choice question below which one best describes your attitude?

I feel powerless and stuck.

I trust the medical team and want to augment their support.

Changing from feeling helpless reacting to circumstances to charting my own responsible course.

View the stroke as the latest in a lifetime of. Challenges and look forward to overcoming this latest challenge.

Also please ask in your own words up to three questions you want answered.

My life changing medical event is not a stroke and I want to book a call for the proof of concept offer. * I have agreed to the terms & conditions for book a call

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