Choose You Program, inspiring people to find their purpose, clarity and

'Choose You' Application Form

Please complete all of the fields in the form below to submit your application.

Full name:		Male Female
Postal Address:

City:		Postcode:
Country:
*Please include area codes for phone numbers*
Daytime Phone:	Mobile Phone:
Work Phone:	Fax:
Email address:

What outcomes would you like to take away or achieve by participating in this program?

Please describe yourself and your current feelings/challenges, include any strong beliefs about yourself and/or any limiting beliefs:

When was the last time you set a goal? Please give a description of how you feel currently about setting and achieving goals:

How do you describe your communication style? Please include any profiles you have done eg. MBTI, DISC, Wealth profile etc.

In order to best serve and support you, please describe yourself when working in a group using the scales below:
1 = Quiet Observer 10 = Outspoken
1 = Nervous, lacking confidence   10 = Completely comfortable, confident
1 = Introverted   10 = Extroverted

On a scale of 1-100, 1 being not at all, 100 being absolutely, bring it on, I'll do everything it takes, please indicate your level of willingness to participate and contribute to the group and the program?

What, if any, pressing questions do you have:
a) about your life/current situation?

b) about the 'Choose You' program?

If there are any other thoughts you would like to share, please do so:

With the intention of fitting with as many people as possible, please indicate which of the following times suits you for the teleworkshops:
Tuesday mornings 10.00am BNE time
Tuesday evenings 6.00pm BNE time
Wednesdays 12.00noon BNE time
Comments:

Please indicate the best number to contact you on:

What is the best time of the day to contact you? AM PM

Are you able to commit to being present at all teleworkshops? Yes      No
If no, please elaborate:

Agreements: Please tick the box if you agree to the statement below.
Yes, I agree to be open, honest and respectful of self and others.  I aslo agree to abide by the standards of the program including keeping strict confidentiality and completing all actions and financial commitments on time.

How did you hear about the 'Choose You' program?

if a magazine, newspaper, referral from another website, or other, please specify

Thanks for your time, we look forward to talking with you soon.

with Grati-Tude

Robyn & the 'Tude Team

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