BobProctor Matrixx -- Client Confidential Questionnaire ::

BobProctor Matrixx -- Client Confidential Questionnaire

"Doing at once what needs to be done increases the possibility of success." - Leland Val Van De Wall

Contact Information

*First Name

*Last Name

Street Address

City

State/Province

Postal Code

Country

Phone, Cellphone, Fax

*E-mail Address

*Who referred you to the Matrixx?

Personal Information
The information that we ask for in this section is general in nature and will help us better acquaint ourselves with you.

Name two people who have influenced your life the most. Please state their relationship to you and how they influenced you.

If we asked two of your best friends what your greatest strengths and weaknesses were, what do you believe their answer would be?

Right brain people are very creative, frequently impulsive, with high energy and often deal from an emotional level. Left brain people have a tendency to be more analytical, frequently dominant, desiring a fair amount of order in their life. Place an X beside the characterization that best describes you.
Check any that apply

Left Brain
Right Brain
Both

Place a mark beside the word(s) that best describes you.
Check any that apply

Calm and easy going
Sensitive
Sympathetic
Quickly angered and showing your feelings and emotions
You internalize your anger, joy or other feelings

Place a mark beside the statement that best describes you:
Check any that apply

You make friends quickly and enjoy being with others socially.
You have close intimate friends and generally feel uncomfortable in social settings.

Place a mark beside the words that best describe how you deal with money:
Check any that apply

Spend it quickly
Keep it and bargain a lot
Love to earn it
Not overly concerned with it

What is the most you’ve ever earned in a year?

Gross Earnings
Net Earnings

What is your current yearly income both gross and net?

Gross Yearly Income
Net Yearly Income

What would you like to earn in a year??

If your income was completely cut off, how long could you maintain your current lifestyle?

How many sources of income do you currently have?

What personal development programs have you attended in the past?

Program Objectives
Though we assume that one of your program objectives is to increase your income, we want you to know that this program is holistically based. With that in mind, we want you to look at your life as a whole and pick certain areas where you would like to see improved results: spiritually, in your relationships, physically, mentally, educationally, etc. Your goals need to be quantifiable - it’s not enough to say that you want more money or want to lose weight. You need to work with a specific objective in mind.

Being as specific and brief as possible, describe exactly what you would hope to accomplish from the Bob Proctor Matrixx Program?

What is your income objective for the year?

List 3 additional areas of your life where you would like to see a marked improvement over the next year and list a goal for each area.

What's Holding You Back
Knowing that our paradigms make and break us, we want you to be totally honest with yourself and really think about your habitual behavior and conditioning and how it affects your life. One of our objectives will be to make you critically aware of this behavior and assist you in changing it. It’s not possible to get different results without breaking through some of the limiting beliefs you may have of yourself or your capabilities.

With your program objectives in mind, what 4-6 habits do you believe may be holding you back from the type of results you desire in each of the areas you have chosen? If the habits are more predominant in one area over another, please state what the habit is and why you feel it affects you in that specific area.

What do you fear and why? (i.e. success, failure, being alone, meeting new people, etc.):

Business History and Financial Background

On a score of 1-10 (with 10 being high), what is your level of expertise in your field?

Do you have your own business?

Does your business require your presence? Explain why or why not.

Think of two or three very successful people with whom you are familiar – what is it about their way of doing business that you admire and would like to make a part of your habitual behavior?

[Exit and Clear Survey]