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Name *
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Email *
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Your social media profile (Facebook/Instagram/LinkedIn profile link for identity verification) *
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What is the #1 breakthrough you want to achieve most? Why is it so important for you? *
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What do you think is the biggest challenge that’s holding you back from achieving this breakthrough? *
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On a scale of 1 to 10, rate your level of physical health *
Describe the most common physical health symptoms that have been bothering you. *
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On a scale of 1 to 10, rate your level of happiness and peace of mind in the past one month. *
I'm depressed and greatly distressed I cannot function normally in my everyday life
I feel fully alive and happy. I have an inner sense of peace.
You're someone who gets really stressed out when.... *
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What services, courses, books or programs have you tried to solve your problems? List them and describe why they didn't work for you. *
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Imagine your current situation never improves and worsens with time. What would your default future look like? What would the cost be to stay stuck? Describe as much as you can. *
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If you were to have a conversation with Val 1 year from today, what would you like to have happened in your personal and professional life to be happy with your progress? *
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How willing and able are you to invest in your personal growth and breakthrough now? *
While most people want a breakthrough, not everyone is willing and open to receive the level of support necessary and take action on their part. Tell us why it’s so important for you to achieve your desired breakthrough. *
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Just for fun - what's one of your secret dreams? *
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