Name
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First Name
Last Name
Email
*
Phone
(###)
###
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Age
*
Location / Time Zone
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What draws you to this work?
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What kind of support are you looking for?
*
What challenge or area of life do you feel most stuck in right now?
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Do you have a desire to become a father (or deepen your role as one)?
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Yes
No
Unsure
If yes or unsure, tell me more about what’s coming up for you around fatherhood.
On a scale from 1–10, how ready are you to make real changes in your life?
*
Why that number?
*
How much do you care about becoming a better version of yourself?
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It's not a big focus
I think about it a lot but haven't taken action
I'm actively working on it
I'm ready to do whatever it takes
Describe what a better version of yourself would look like.
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How would he think, feel, show up differently than you do now?
Have you worked with a coach, therapist, or mentor before?
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Yes
No
If yes, what worked and what didn’t?
What’s your vision for the next 6–12 months?
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What’s in the way right now?
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This work involves commitment. Are you ready to invest time, energy, and finances into yourself?
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Yes
No
I want to, but I'm not sure I can
If you're unsure, what's your biggest hesitation?
Anything else you'd like me to know about you or your story?