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Keeping the Balance in You ~ Feedback Survey

Welcome!  Devote the next 3-5 minutes of your time to complete this short feedback survey, and–depending on availability–you may qualify for a 30 minute breakthrough session with me. It will be totally confidential, one-on-one, and it's valued at $87.50. So fill out the survey in full, including your accurate contact information. By answering the questions below you will receive the benefits that come from honest self exploration and identification.  Also, someone on my team can get in touch with you to schedule the phone session with me. (Note: If we DON'T get in touch with you right away, it's because I'm all booked out and unable to fulfill any more coaching sessions.)

*Please also note details and descriptions in each question regarding the coaching session, as some answers will disqualify you (I do have a limited number of seats and only work with those who are ready, coachable and committed to living the lifestyle and making the impact they know they're capable of). Thank you, and talk to you soon! Hugs! Jessica

Your personal information

Last Name  
First Name  
Email address  
Primary phone number  
Shipping Address:    
Street address  
Apartment or unit number  
Birthday (mm/dd/yyyy)  

Your Life Situation

Please tell me about your current life situation. Answer both questions below. Hint: what has your most focus, what worries you, or what feels like major hurdles that you have to move beyond in order to have the lifestyle you truly desire?


What is key motivator for you to seek a change now?  


What is working for you in your life right now?  


What is not working so well in your life right now?  


What are your top five concerns in order of importance?  

Your Life Goals


What are the top 3 biggest challenges you face in your life today and want to change sooner than later?  


What is important about overcoming these challenges?  


How long a period of time do you feel that you would commit to overcoming these challenges?  


What have you successfully done or unsuccessfully done in an attempt to overcome those challenges?  


Tell me about the lifestyle you are ready to have ... in particular what you want and why (for now, do not to think about how).
Hint: What is your life dream? If you could have it your way, what style of life would you be living? Just tell me about 4-5 things that are really important to you.   


In your life you are living, how close are you to living that successful life you so deserve right now?  


On a scale of 1-10, how strong is your desire to master the mind set and skill set that will help you succeed in this endeavor — and ultimately, enable you to start living your lifestyle whole heartedly, and with ease, exactly the way you described it above?
Note: If your desire is anything below an 8, I will not be able to work with you as a private or group coaching client, and will not be contacting you to schedule your coaching session. That said, please be honest in your answer.  

Low Priority
About as interesting as yawns, cardboard, laundry, and waiting in line at the DMV.


Top Priority
As desirable as amazing sex, organic dark chocolate, and total freedom (including the resources you need) to make your greatest contribution to the world.


Knowing your learning style and preferences, including frequency, intensity and support levels, which would you find most helpful and satisfying as you deepen your education and understanding the balance of lifestyle?

Please check all that appeal to you based upon your needs and schedule.


Now that you are thinking about beginning a coaching experience, which of these things would you say are true...


What would you like to add that you have not  had a chance to say to get started? What specifically do you want from here that would make all the difference in your life and business/career?


How were you originally introduced to Keeping the Balance in You?






Thank you for choosing Keeping the Balance in You.
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