Thank you for completing the first step!

We’re excited to have you with us on this journey!
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Should you experience any issues or don’t receive further updates, feel free to reach out to us at admin@steffiewillems.com.

Next Step: Fill Out the Questionnaire

This questionnaire helps me gain a clear understanding of how self-sabotage affects your life. It ensures I’m well-prepared to offer the best support possible throughout the challenge.
Rest assured, your responses will remain confidential and will only be reviewed by me and my team. Your privacy is important to us, and this information is solely for the purpose of the challenge.

Name *

First

Last

Whatsapp phone number (Re-enter for confirmation)

FAMILY: What is your current family situation? (single, married, with children, …) *

How Satified are you with your current family situation? *

• Very Unsatisfied
• Unsatisfied
• Neutral
• Satisfied
• Very Satisfied

Do you feel self-sabotage is affacting your family situation? *

• YES
• NO

WORK/ CAREER: What is your occupation *

How Satified are you with your current job? *

• Very Unsatisfied
• Unsatisfied
• Neutral
• Satisfied
• Very Satisfied

Do you feel self-sabotage is affacting your work or career? *

• YES
• NO

FINANCIAL: Are you the primary provider for yourself or your family? *

How Satified are you with your current financial situation? *

• Very Unsatisfied
• Unsatisfied
• Neutral
• Satisfied
• Very Satisfied

Do you feel self-sabotage is affacting your financial situation? *

• YES
• NO

SOCIAL LIFE: How Satified are you with your current relationships/social life? *

• Very Unsatisfied
• Unsatisfied
• Neutral
• Satisfied
• Very Satisfied

Do you feel self-sabotage is affacting your social life? *

• YES
• NO

HEALTH AND WELL-BEING: How do you feel about your current health state? *

• Very Unhealthy
• Unhealthy
• Neutral
• Healthy
• Very Healthy

situation are with

Do you feel self-sabotage is affacting your physical and mental health? *

• YES
• NO

Feel free to share anything you'd like to add about your current situation (optional)

MOTIVATION FOR CHANGE: Why do you want to stop self-sabotaging now? *

On a scale of 1-10, how committed are you to making a change in your life? (0 = Not Committed, 10 = Fully Committed)

Selected Value: 0

What do you hope to achieve by participating in this challenge? *

Verification *

• I have filled out this form truthfully

Submit