What best describes your current status?
Select OneActive executive / senior leaderBusiness owner / founderRecently transitioned / exitedSemi-retiredOther

Where are you right now with your relationship status?
Select OneDivorced — fully settledDivorced — recentlySeparated or in active divorce proceedingsMarriedSingle

How would you honestly describe where you are right now?
Select OneSomething is off but I cannot fully name itI have lost my edge and I know itI am successful on paper but it does not feel like enoughI am in a major transition and I need to get clearI have been carrying too much for too long and I am done pretending

How long have you been feeling this way?
Select OneA few monthsAbout a year2-3 yearsLonger than I want to admitIt hit me recently but hard

What is it costing you to stay where you are?
Select OneMy confidence and sense of selfMy relationshipsMy health and energyMy professional performanceAll of the above — everything is being affected

What made you reach out now vs. 6 months ago?
Select OneSomething recently happened that I cannot ignoreI have been putting this off and I am done doing thatThe pain has gotten bad enough that I have to moveI finally admitted to myself that I cannot solve this aloneI am not sure — something just told me it was time

What best describes what you are looking for right now?
Select OneI know what I want — I need structure and accountability to get thereI am clear something needs to change but I am not sure what yetI need to get out of where I am — I will figure out the direction afterI am still figuring out if I am ready to do this at all

How ready are you to actually do something about this?
Select One10 — I am ready and I mean it7-9 — Ready but with some hesitation4-6 — Interested but not fully committed yet1-3 — Still figuring out if this is right for me

Your most recent private investment in yourself was closer to:
Select One$5,000$7,500$10,000$10,000+This would be my first serious investment

Are you in a position to invest seriously in solving this now?
Select OneYes — if it is the right fit I am ready to moveLikely yes — I need to know more firstI am not sure yetNo — not at this time

Have you tried to fix this on your own? What happened?
Select OneYes — I have tried and keep ending up in the same placeYes — I made some progress but nothing has stuckI have thought about it but have not taken real actionNo — I have been avoiding it entirely

What has stopped you from dealing with this until now?
Select OneDid not want to admit something was wrongCould not find the right person to work withToo busy — but that is changingWas not ready to be honest about itNothing has stopped me — I am ready right now

Do you have someone in your life holding you accountable right now?
Select OneNo — I am carrying this aloneI have people around me but nobody who really challenges meSomewhat — but not at the level I needYes — but it is not enough

Have you worked with a coach before?
Select OneNeverOnce or twiceYes regularlyCurrently working with someone

In one or two sentences — who were you five years ago versus who you are today? (Optional but valuable)

Anything else you want me to know before we speak? (Optional)