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Fill out the form below to find out if you are really ready to manage your drinking.
Email address *
First Name
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Last Name
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Age
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Where do you live? (City, State, Time Zone)
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Best phone number to reach you:
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Highest Level of Education completed
What is your profession?
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What’s your combined family income?
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Are you currently drinking?
How many days of the week do you drink on average? (If you are on a break use your pre-break average)
How many drinks do you consume in a typical sitting? (If you are on a break use your pre-break number)
Why are you serious about changing your drinking now?
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How determined are you to work towards change?
Not Ready
100% Committed
Why are you serious about changing your drinking now?
Your answer
How determined are you to work towards change?
Not Ready
100% Committed
Why did you select this number? (If it’s less than a 5, what’s holding you back?)
Your answer
What have you tried in the past?
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Why do you find it difficult to change your drinking?
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What do you think has prevented you from changing your drinking thus far?
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Why are you interested in coaching as a solution to this problem?
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What will success look like for you in 6 months?
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Will you show up on time for your call?
What are you most excited about with your call with Mary?
Your answer
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