Complimentary Consultation

First Name:*

Last Name:*

Address:

City:

State:

Zip:

Email:*

Phone:*

Alternate Phone:

How did you hear about me?*
Radio ShowReferralSpeaking EngagementInternet SearchWebsiteFacebookTwitterPinterestBook

What do you hope to Achieve by working with Me?*

How Does this problem Hold you back in Life?

What Have You Tried So Far That Hasn't Worked?*

How Important is it to Overcome this issue now?*

If You Could Create Your Ideal Solution, What Would it Be?*

After 12 months, if you resolve this issue, what is your life like now?*

What Do You Think Holds You Back From Achieving Your Dreams/Goals/Ideal Life?*

Tell Me About Your Faith/Spiritual/Religious Beliefs.*

Have You Invested In Coaching Before?*

How Much Money Have You Invested in Yourself in the Past 12 Months?*

Clothing, Spa, Workshops, Vacations, etc...

Please Tell Me What You Expect to Get from My Programs*

How Committed Are You to Changing in Order to Achieve Your Goal to Live a Happier, More Fulfilled Life?

Describe How You Stop Yourself When Trying Something New or Facing a Challenge.*

Tell Me anything Else You Want Me to Know Before we Speak.*

By submitting this application I acknowledge that I am interested in coaching and or training services and will receive a complimentary 20-30 minute phone consultation with Lance Jaynes.

I understand that space is limited and acceptance in this program is based on availability. I understand that participating in one of Lance's programs requires a financial investment and I am ready and able to make that commitment to myself for personal development.