NAME, CLAIM AND REFRAME® PROGRAM
Your power and potential start with your truth!

The following information will be held in confidence and will assist me in gaining a clear view of who you are now, who you want to be and what you want to accomplish through our work together in NCR. Thank you for taking the time to complete the questions.

PERSONAL INFORMATION

Applying for:

Name

First Name

Last Name

Pronouns:

Phone

Country

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth (Year Optional)

YYYY

AN ALCHEMY OF YOU…Think about it!

An optional Reflection. The following prompts can help you set intention and get your juices flowing for what can be possible when you integrate NCR into your life. While it's not mandatory, I find this front-load reflection will enrich our workshop conversations. If you are comfortable sharing these reflections, please take a moment to ponder the following prompts.

1. What do you consider to be your strengths, talents, assets?

2. If I had a magic wand that could make everything flow; What does your life look like? Who have you become?

3. What are you tolerating in your life?

4. What do you want more of in your life?

5. What are the statements that your inner critic says?

6. What generally keeps you from getting what you want?

7. If you could create a dream job what would it be?

8. What is your greatest fear?

9. What is your greatest accomplishment in your life?

10. What is the most difficult thing you’ve ever experienced?

11. What is great about you?

12. What else would you like me to know about you?

NAME, CLAIM AND REFRAME® PROGRAMYour power and potential start with your truth!

NAME, CLAIM AND REFRAME® PROGRAM
Your power and potential start with your truth!