Individual Survey

Your Email Address:
Your Address:
What is your intention over the next 3 months?
1st (Top) Goal?
2nd Goal?
3rd Goal?
List five words to describe how you envision your optimal self:


A copy of your responses will be emailed to the address you provided.

Contact Lori

Please use the form below to contact me and I will reply to you as soon as possible. Thanks again and hope to work with you soon.