Name *

First Name

Last Name

Phone

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1. How do you feel about your relationship with money? *

A. I feel anxious about money and often fear I won’t have

B. I have a love-hate relationship with money; sometimes I’m comfortable, other times I struggle.

C. I don’t think much about money, but I find myself constantly in financial difficulties.

D. I feel confident about money, but I feel blocked from reaching a higher level of abundance.

2. How was money viewed in your family growing up? *

A. We struggled with money, and it caused stress.

B. Money was always a source of tension or conflict.

C. We didn’t talk about money much, but I knew we had financial issues.

D. Money wasn’t an issue, but I didn’t learn much about managing it.

3. Do you notice any recurring financial patterns in your life (e.g., debt, instability, sudden losses)? *

A. Yes, I see these patterns repeating, and I feel stuck.

B. I notice patterns, but I can’t seem to break free from them.

C. I avoid thinking about my finances, even though I know I need to.

D. I don’t have recurring issues, but I feel like I’m not reaching my full potential.

4. How do you feel when it comes to managing your money? *

A. I feel overwhelmed and anxious.

B. I try to stay on top of things, but money feels like a constant struggle.

C. I avoid managing my money, and it often gets out of control.

D. I manage my money well, but I feel like I could do more with it.

5. What do you believe is holding you back from financial success? *

A. My family’s history and struggles with money.

B. My own fear of failure or success.

C. Lack of financial education or guidance.

D. Something intangible—I’m not sure what’s blocking me.