Welcome and congratulations for being at a special place in your life...a place where you are sincerely interested in creating meaningful breakthroughs from the inside out.
So you will get the absolute most from your no-cost, initial Breakthrough Session...please complete your answers on the form below. Then, in order to get the very most from this special meeting, please email your completed form to your LCA Consultant before you meet.
We look forward to sharing this important time with you.
Home Phone: _____________________________ Cell Phone: _____________________________
Work Phone: _____________________________ Email: _________________________________
Date of Birth: ____________________________
1. What are your greatest current Unworkabilities? An Unworkability is any area of your life that isn’t working as well as you would like. They can be INTERNAL such as fear, guilt, resentment, self judgment, lack of confidence, low motivation, hurt from the past, depression, procrastination, etc...or they can be EXTERNAL such as career, relationships, finances, living environment, family issues, health, etc. The more Unworkabilites you can list, the more pieces to the puzzle we will have to work with.
2. What are your greatest dreams? When you look DEEP into your heart, (if the above Unworkabilities were handled and you had 10 times your current level of energy, discipline and self confidence) what would be the dreams of your heart...the things you would love to be, do or have in your lifetime? Again, the more you can list, the better.
3. What happened when you were growing up, where you got hurt and may have created limiting judgments about yourself? You cannot grow up in our culture and not get hurt. It’s happened to all of us. Even in the best of families, painful events happen. A key place to focus is your relationship with your parents and siblings.
________________________________________________________________________________________ 4. Are you currently seeing a therapist? _____ If so, are you satisfied with the results you are achieving? _____
5. Are you currently on medication for mental/emotional issues? _____
6. Do you have any addictions such as alcohol, illegal drugs, food, work, TV, sex, sleep? _____ If so, to what are you addicted?
10. Have you been experiencing a high level of stress/fear? _____ What level of stress are you experiencing on a scale of 1 to 10 (where 1 is virtually no stress and 10 is extreme stress)? _____
11. Have you been seriously contemplating suicide? _____. If so, WE STRONGLY SUGGEST YOU SEEK IMMEDIATE ASSISTANCE FROM A QUALIFIED PRACTIONER or call the National Suicide Prevention Lifeline at 1-800-273-8255!
12. What would you say is your motivation level to resolve your Unworkabilities and bring forward your Dreams on a scale of 1 to 10 (1 being extremely low motivation and 10 being extremely high motivation). _____
13. How did you hear about the LCA (or who introduced you to us?) ______________________________