Pre-Engagement Survey - The Clutch Club™ Platinum
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First Name: *
Last Name: *
Email address: *
Phone Number *
Address *
City, State, Zip *
Who referred you and what's your relationship to him/her? (e.g. John Doe, my agent) *
What are you? *
What's your average annual income? *
Date of Birth *
Gender *
Relationship Status *
Do you have kids? *
If you have kids, what are their ages (if no kids, please skip to next Question)
What are you interested in doing with J.R. (select all the apply)? *
Required
Briefly, describe how you heard about the Champions Ranch™ and why you’d like a Quick Win Call with J.R.? *
Scale Questions - Clutch Life Categories™
Rate yourself in each category based on the last 90 days of your life.
(1 = This isn’t even close! I’m struggling big time in this category; 10 = This is totally me. I’m crushing it!)
PHYSICAL - I regularly take care of myself so that I can feel my best. I want my overall health dialed in so I’m energetic and strong each day. I commit to eat clean, get my required hours of sleep, and train my body so that I have the physical vibrancy and stamina to reach optimal levels, enjoy life, and deal with its hurdles and opportunities. *
MENTAL/EMOTIONAL - I have a positive attitude and perspective. I live and compete with a sense of joy and peace and regularly experience positive emotions and relationships. I’m mindful of the energy, focus, and emotions I want to have and generate in life. *
SIGNIFICANT OTHER/LOVE - I feel a consistently deep, trusting, grateful, and loving connection with my significant other. I’m patient, respectful, and pay attention to my significant other’s needs. **IF SINGLE**: I live each day with a sincere compassion and love for others. I seek to have deep, meaningful, and joyful relationships. *
FAMILY - I’m consistently present with my family and have a fun, positive, and deep connection with them. Others around me would say that I love my family and am doing my best for them. I forgive my family easily and am compassionate with them. *
FRIENDS/OTHERS - My inner circle inspires me and brings connection, fun, and positive energy into my life. I seek out positive people and weed out the negative. I do my very best to bring positive energy and real authenticity into all my relationships. I spend enough time with my friends. *
MISSION - I feel clear, energized, and fulfilled by my contributions to the world. My efforts add real value to the world and reflect the best version of me. What I do makes me feel alive and engaged - it feels like a mission, calling, or purpose. *
HOBBIES/INTERESTS/COMMUNITY SERVICE - I give enough time to the things I enjoy in life, including my hobbies, interests, and service to the community. I go on vacation, seek adventures, and schedule nights out with others. *
SPIRITUAL - I feel connected to the present moment and vitally alive in my spirit. I’m living and acting in alignment with my beliefs and I keep my faith and values at the forefront of my daily decisions and actions. *
FINANCES - I’m responsible with my money and saving for my future. I’m learning the skills necessary to earn more and invest. I enjoy my lifestyle and allow myself to reap the fruits of my labor. *
LEARNING/INTELLECTUAL DEVELOPMENT - I’m curious and pay attention to the world around me. I ask questions so that I can learn new things. I seek to discover new things about myself and others. I’ve created a personalized curriculum for myself so that I can develop the skills needed to succeed. *
Scale Questions - Performance
Rate yourself in each category based on the last 90 days of your life.
(1 = This isn’t even close! I’m struggling big time in this category; 10 = This is totally me. I’m crushing it!)
#1 - I’m clear about who I am, my purpose, and the direction I want to go in my life and career. *
#2 - I have a game plan that’s written down and I review and refine it regularly. I’m consistently focused and effective at executing my game plan, as well as great at minimizing distractions, overcoming challenges, and maintaining my priorities. *
#3 - I treat my life and career like a game. I’m clear on what the most important activities are for achieving my life and career goals and hold myself accountable to them. *
#4 - I take my goals seriously and embrace accountability to others when it comes to achieving them. I have an Accountability Partner that makes me want to achieve everything I’ve set out to do and accomplish. *
#5 - I have several routines that set me up for success in life and my career. I consistently follow-through on these routines and have a system for evaluating them to make sure they’re always serving me and pushing me to my highest level. *
#6 - Everything in my life is scheduled on a calendar. I’m clear about what my ideal week looks like and have strategies in place to protect my schedule, time, and the things that matter most to me. *
#7 - I use tools and technology as part of a system to keep me on-schedule and on-task on a daily basis - things like a journal, digital calendar, digital notebook, email provider, and online file storage. *
#8 - I take action and consistently express and communicate who I truly am, as well as what I think, need, and desire. *
#9 - I have the social influence with my family, friends, and team that’s needed to accomplish my goals. *
#10 - I have a reliable way to suspend any disbelief(s) or lack of confidence in my ability to show up and perform at my best during key moments of impact in the various roles I play in life. *
#11 - I’m the person who wants the ball in my hands when the game is on the line. I live for intense pressure situations and have an intentional strategy for locking in during those moments. *
#12 - I’m clear on the number of hours of sleep that I need to perform at my best. I have a plan in place to recover fully each day, and I’ve designed my own way for measuring my progress. *
#13 - I’m clear on the diet that I need to follow in order to fuel my body and mind for optimal performance. I have a plan and system in place for elite nutrition, and I’m equipped with the resources needed to measure my progress. *
#14 - I have at least one hobby that I consistently use to recover and take my mind off my career. I approach my hobby strategically so I can maximize its ability to help me recover. *
#15 - I’m clear on the breathing protocol that I need to follow to oxygenate my body and prepare my mind for optimal performance. I have built this protocol into my daily routines and I’m equipped with the resources needed to measure my progress. *
#16 - I have a meditation practice that I consistently follow to achieve elite mental and emotional fitness. I have built this practice into my daily routines and I’m equipped with the resources needed to measure my progress. *
#17 - I have a visualization / mental imagery practice that I consistently follow to achieve elite mental and emotional fitness and prepare for the highest levels of competition. I have built this practice into my daily routines and I’m equipped with the resources needed to measure my progress. *
#18 - I have a practice that I consistently follow to achieve elite level focus. I have built this practice into my daily routines and I’m equipped with the resources needed to measure my progress. *
#19 - Overall, I’m typically living in the present moment. I live by the mantra, “What’s Important Now?” I have a high level of self-awareness and a reliable way to center myself when my mind is drifting. I have the capacity to objectively evaluate my own behavior, even when I’m emotionally fired up. *
#20 - I have my technology under control. In other words, I’m intentional about my time on things like social media and applications on my mobile devices. I don’t suffer from FOMO (Fear Of Missing Out) and I rarely catch myself mindlessly scrolling social media and the news. *
#21 - Overall, I have a high level of self-control and discipline and make decisions based on long-term results (vs. instant gratification). I’m intentional about putting protective measures in place so I don’t compromise my performance, goals, relationships, and reputation. When I put my mind to something, no one and nothing gets in my way. *
#22 - I’m great at motivating myself to do the hard, boring, or monotonous things to be successful. *
#23 - PRO & OLYMPIC ATHLETES ONLY: I have a visual training practice used to improve the speed and efficiency with which my brain processes information and gets my body to respond the way I want it to.
Clear selection
#24 - PRO & OLYMPIC ATHLETES ONLY: I have a structured process for preparing and reviewing my specific theme, plan, and strategies for the off-season, pre-season, and in-season months. I feel confident in my process and block significant time each year to complete it.
Clear selection
#25 - PRO & OLYMPIC ATHLETES ONLY: I have a structured process for preparing and reviewing my specific theme, plan, and strategies for pre-, in-, and post-game/competition. I feel confident in my process and block time to complete it.
Clear selection
Open-Ended Questions - Performance
#26 - Why are you doing what you do for a living? If you’re a pro athlete, why are you playing your sport? *
#27 - What are the Top three (3) Goals you’re striving for right now? *
#28 - What major stressors or challenges are you struggling with right now? *
#29 - When you feel like your most successful and happy self, what makes you feel that way? *
#30 - What would your ultimate dream life look like if you could wave a wand and make it happen? *
#31 - What’s holding you back from your next level of success? *
#32 - What goal or dream have you ever given up on or failed at? *
#33 - Regarding your answer above, what do you believe caused you to stop or fail? *
#34 - What three (3) BIG changes would you like to make in your life in the next 12 months? *
#35  -What are you most proud of and excited about in your life? *
#36 - What negative recurring thoughts, fears, or behaviors would you like to overcome in order to feel more free in your mind, as well as more confident and successful? *
#37 - What eating, exercise, or general health habits would you like to begin or break in order to feel stronger and more healthy? *
#38 - What distracts you the most? *
#39 - What major projects or missions are you struggling to complete faster or more efficiently? *
#40 - If you were more persuasive or influential, what dream or desire would you ask others to support you to achieve? *
#41 - When do you struggle to be fully present in your day or in any of your relationships? *
#42 - How purposeful do you feel in living each day? *
#43 - How would you describe your purpose? *
Closing Questions
Have you invested in any type of personal, leadership, or human performance coaching before? If yes, how was your experience? *
What have you been putting off that you know would be beneficial if you started now? *
Two-part question: 

1.) What do you want more than anything? 

2.) What hurdle is in the way of it RIGHT NOW (that, if jumped, you'd take one big step towards what you want)?
 *
Why would you like to work with J.R.? *
Why do you feel you would be a great client of J.R.’s? *
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