Wufoo
About You...
Name
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First
Last
Phone Number
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Time Zone/Country
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Email
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What is your age?
What do you most want to change today?
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Have you tried to change this before? Explain what you've done and how it went.
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Why do you think it didn’t work?
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On a scale of 0-10, how important is it for you to achieve change today?
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What other areas of your life do you want to change (if any)?
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