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Empower Yourself Questionnaire

Please answer the following questions.

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Question 1 of 15

Personal Details (optional) 

Name: 

Email: 

Age: 

Gender: 

Location: 

Your Current and Desired Reality 

I'd love to know more about where you are at right now and where you wish to go. 

 

Please answer the following questions:

Question 3 of 15

 

What are the top 1-3 biggest challenges you are experiencing right now? 

Question 4 of 15

How are these challenges impacting your current reality? Note down any feelings, thoughts, or behaviors you are experiencing. 

Question 5 of 15

Let's journey deeper. Why do you think you may be experiencing these challenges? Have you tried overcoming them before and how so? 

Question 6 of 15

What are your top 1-3 desires you wish to experience and move towards?

Question 7 of 15

How would living this desired reality impact you? Note down any feelings, thoughts, or behaviors you would be experiencing. 

Question 8 of 15

Let's journey deeper. Why do you actually want to experience this desired reality? 

Breakthrough the Blocks

Let's uncover what's standing in your way from stepping into your most desired reality. 

 

Please answer the following questions: 

Question 10 of 15

What's stopping you from taking action toward your desired reality? 

Question 11 of 15

What fears or emotions are holding you back from stepping into your desired reality? 

Question 12 of 15

What beliefs or mental stories are holding you back from stepping into your desired reality? 

Question 13 of 15

If you decide to stay where you are, what is the cost of not moving toward your desired reality right now? Note down any pains of staying where you are. 

Question 14 of 15

Let's imagine you are standing in your desired reality, what results do you get by living in your desired reality? Note down any pleasures. 

Thank you!

Thank you so much for taking the time to complete this form for me. I am so grateful for your help.

Sending so much love + blessings your way.

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