Dirk Schultz M3 Holistic Fitness Assessment ™

EMPOWERING OTHERS TO LIVE BETTER, YEAR AFTER YEAR

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Please answer these questions so Dirk can see if you are a candidate for coaching.
Remember, mindset is key! Your intention creates your reality. Where your focus goes, your energy flows.

"*" indicates required fields

First Name*

Last Name*

Phone*

Email*

What is the change you want to see?*

Why do you want this change?*

How do you want to feel once you create this change?*

Why don’t you already have this?*

What is it costing you by not having this?*

On a scale from 1-10 (1 = not committed, 10 = fully committed), what is your current commitment level to this change?*

What do you think could help raise this commitment level 1-2 points?*

What goal has your gut been telling you to commit to but you haven’t written it down because of fear?*

What would you like your life to look like one year from today?*

Ideally, how would investing in yourself to have Dirk’s support help you?

Consent

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