Personalized Wealth Mentoring With Chuck Danes

Please fill out the short form below and a requested time to contact you between 8:00 am - 6:30 pm North American Eastern Time.

(All coaching/mentoring sessions are subject to availability)

Prescreening Application For Real Freedom
Mentoring/Coaching Program

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Web Site URL

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Country*
Country*

Home Phone*
Home Phone*

Business Phone

What is your primary motivation
for seeking coaching?

(Please be as specific as possible)*
What is your primary motivation
for seeking coaching?

(Please be as specific as possible)*

How do you perceive that this form of coaching can assist you individually?*
How do you perceive that this form of coaching can assist you individually?*

What specific outcome, materially and/or otherwise
do you see yourself achieving should you be selected

(What is your Why?)*
What specific outcome, materially and/or otherwise
do you see yourself achieving should you be selected

(What is your Why?)*

Based on where you are now, what do you "perceive" is keeping or has kept you from achieving your individual desires?*
Based on where you are now, what do you "perceive" is keeping or has kept you from achieving your individual desires?*

How committed are you to the process of achieving your desired results?*
How committed are you to the process of achieving your desired results?*

What do you perceive your
greatest strengths to be?*
What do you perceive your
greatest strengths to be?*

What do you perceive your
greatest weaknesses to be?*
What do you perceive your
greatest weaknesses to be?*

In what way do you feel Chuck can best serve you
in the attainment of your individual desires?*
In what way do you feel Chuck can best serve you
in the attainment of your individual desires?*

	Mindset Coaching
	Processes Coaching
	Both

Do you consider yourself as being able, open, receptive and willing to follow specific steps and guidance relating to fulfilling your envisioned outcome? *
Do you consider yourself as being able, open, receptive and willing to follow specific steps and guidance relating to fulfilling your envisioned outcome? *

On a scale of 1-10 how self-directed are you?

1 = I achieve my best with someone else showing me step-by-step

10 - I prefer to achieve independently with minimal guidance or input from others

(Please explain)*
On a scale of 1-10 how self-directed are you?

1 = I achieve my best with someone else showing me step-by-step

10 - I prefer to achieve independently with minimal guidance or input from others

(Please explain)*

Are you ready to move forward immediately
if accepted into the curriculum?*
Are you ready to move forward immediately
if accepted into the curriculum?*

Do you have the immediate availability of financial resources neccessary to move forward without imposing a financial burden?*
Do you have the immediate availability of financial resources neccessary to move forward without imposing a financial burden?*

What is your current occupation?*
What is your current occupation?*

	Business Owner
	Employee
	Retired
	Unemployed
	Other

Do you have consistent access to a computer
and an internet connection?

(Mentoring sessions are held online)*
Do you have consistent access to a computer
and an internet connection?

(Mentoring sessions are held online)*

What is the best way to contact you
should we have additional questions?

ie. home phone, business phone, email*
What is the best way to contact you
should we have additional questions?

ie. home phone, business phone, email*

Do you currently have either Oovoo or Skype
internet communication services?
(If yes enter username)*
Do you currently have either Oovoo or Skype
internet communication services?
(If yes enter username)*

Any Additional Comments, Question or Concerns That May Assist Us In Considering Your Application?

Please enter the word that you see below.

Here's How an Online Business and Wealth Mentoring
Can Make You Rich "AND" Happy