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Starting Evaluation
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Your Email Address
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Your Birthday (Month/Day)
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Address
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Street Address
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Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
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Belarus
Belgium
Belize
Benin
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Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
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Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
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Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
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El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mauritius
Mayotte
Mexico
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Monaco
Mongolia
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Montserrat
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Mozambique
Myanmar
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Nauru
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Nigeria
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Panama
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Portugal
Puerto Rico
Qatar
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Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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Saint Vincent and the Grenadines
Samoa
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Thailand
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Virgin Islands, U.S.
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Your Phone (+ area/country code)
(Required)
Best Time To Call You
When is the best time for us to reach you via telephone?
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Early Afternoon
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Starting Evaluation
Have you experienced the Unstick Your Mind Program before as a Student?
(Required)
Yes! I'm a returning student.
No this is my first session.
Do you have access to a reliable computer & a strong Internet connection?
(Required)
We prefer you to use a computer and not an ipad or phone to join calls, and we advise against driving during calls. You will need a good quality camera and microphone or built in mic, and good lighting.
Yes I have a computer & reliable Internet connection.
No I don't have a reliable Internet connection.
I don't right now but will get it organized.
Are you familiar with using Zoom?
(Required)
Yes I have experience using Zoom & have my own account.
No I'm not familiar with Zoom.
Your Timezone EST/CST etc (see https://www.worldtimebuddy.com)
Preferred Hours to Attend a Small Group
(Required)
Please tell us what time slots and timezone you are available for to join a group for 12 weeks.
Monday
Tuesday
Wednesday
Thursday
Friday
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Section Break
What do you love most about your life right now?
When you are at your best and life feels as good as it can be, how would you describe yourself?
If you had a magic wand, what three things would you change about your life?
What are your current challenges and frustrations that keep you up at night?
What is holding you back from achieving your dreams? Do you know what it is?
Section Break
Where do you want to be after this process? What are your goals?
What or who motivates you to keep dreaming?
Select three areas that are most important to the quality of your life.
Section Break
Identify one goal that you want to be your main focus for your coaching. Provide a simple heading & a description of measurable results that you need to see & feel in that area. Think about what you will need to feel like you are making significant progress, success and experiencing feelings of satisfaction. Be specific.
What is your God-given vision for your life in the next three years - what are the secret parts that you haven’t even dared to fully articulate yet?
What is your BIG overall life dream?
How committed are you to your God-given vision - doing whatever it takes, being open to new ways of thinking, being, and speaking and making the time for your vision? (On a scale of 1 - 10 with 1 being “not at all”, 5 being “somewhat” and 10 being “YES”!)
Section Break
What is the biggest belief and habit you need to let go of to fully allow your God-given vision to manifest?
What do you think is holding you back?
Where do you usually get stuck in achieving your goals?
What happens when you are frustrated or not making progress?
What motivates you to change when you get stuck?
When you are frustrated, how do you sound, what do you say, how do you show up?
How do you deal with disappointment or failure?
Section Break
How are you with staying the course and sticking to your goals for the long term?
How are you with saying no and setting boundaries?
What would you like to see happen in the next 90 days? What would you like to see happen one year from now? What do you want to change?
Is there anything else you’d like to share that you believe we should know?
Terms and Conditions
(Required)
All payments are final and there are no refunds or cancellations allowed for any reason. Please note that your enrollment in the Unstick Your Mind program does NOT include group coaching. We offer limited availability for small groups during the year. These are priced separately and will be an additional fee. You will be invited to join a group for the 12 weeks of small group coaching when we open doors for enrollment. You may attend as many rounds of small group coaching as you need, at our special renewal rate. You will have the option whether or not to rejoin your group, or a new group, for another 12 weeks of coaching.
I agree to the terms and conditions.
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