Client Application

Your Name*

Your Email*

When is your birthday?

Where can we reach you by phone? (xxx-xxx-xxxx)

What would you most like to accomplish in our time together?*

How hard do you want to be pushed?* (1=none, 10=hard)

—Please choose an option—12345678910

How How do you FEEL about achieving that goal?

What barriers do you see in achieving this goal?

What are you doing to overcome those barriers?

How will your life be different after you achieve your goals?

Is there anything else you want us to know?

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Finally, we do need to make sure you're a human. (Sorry.) enter the code below into the box and then click "send."

If you cannot read this, please refresh the screen; if you still cannot use it, send an email to scottq(AT)thistimeimeanit.com

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Someone will get back to you quickly.

Please tell us who you are. (required):

Contact email (required):

Best number to reach you:

Organization:

Your message:

Tell us where you found out about Scott
(Scroll down to share how you found Scott.)I found Scott via an Internet SearchI found Scott through a friend or associateI had worked with Scott beforeI know Scott personallyI cannot remember; just lucky I guessOther

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Finally, we do need to make sure you're a human. (Sorry.) enter the code below into the box and then click "send."

If you cannot read this, please refresh the screen; if you still cannot use it, send an email to scottq(AT)thistimeimeanit.com

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