Application Form

{"0":{"lid":"1587045481388","ls":"10","loff":"","li_type":"tx","li_text":"<div style=\"font-size:20px;text-align:center;color:rgba(213,22,46,0.83);\" data-customstyle=\"yes\"> All information is kept strictly confident and will never be shared with any of third parties!</div>"},"1":{"lid":"1531306540094","ls":"20","loff":"","li_type":"nm","li_name":"name","li_ph":"Your Name","li_req":"y","li_nm":"name"},"2":{"lid":"1587010939172","ls":"30","loff":"","li_type":"ta","li_ph":"Address","li_req":"y","li_rows":"3","li_nm":"Textarea"},"3":{"lid":"1587054811164","ls":"40","loff":"","li_type":"ph","li_ph":"Phone","li_req":"y","li_masktype":"a","li_nm":"Phone"},"4":{"lid":"1531306243545","ls":"50","loff":"","li_type":"em","li_name":"email","li_ph":"mail@example.com","li_req":"y","li_nm":"email"},"5":{"lid":"1587010998126","ls":"60","loff":"","li_type":"da","li_name":"dob","li_title":"Birth Date","li_req":"y","li_dateformat":"YYYY-MM-DD","li_datediv":"dash","li_nm":"dob","li_datemask":"9999-99-99"},"6":{"lid":"1587011032967","ls":"70","loff":"","li_type":"rd","li_name":"Sex","li_title":"Sex","li_variants":"F\nM","li_radcb":"rb","li_nm":"Sex"},"7":{"lid":"1587011073426","ls":"80","loff":"","li_type":"sb","li_name":"Marital Status","li_title":"Marital Status","li_variants":"Single\nHave a partner\nMarried\nCommon-Law\nDivorced\nWidowed\n","li_defselitem":"1","li_nm":"Marital Status"},"8":{"lid":"1587042036895","ls":"90","loff":"","li_type":"sb","li_title":"How did you know about the training?","li_req":"y","li_variants":"Facebook Live\nWebsite\nFacebook Group\nGoogle Search\nInstagram\nLinkedIn\nFriends\nOther","li_selfirstvar":"Choose one of the options","li_nm":"How did you know about the training"},"9":{"lid":"1587044831801","ls":"100","loff":"","li_type":"in","li_name":"Your Current or Future Business is in","li_ph":"Your current or future business is in:","li_req":"y","li_nm":"Your Current or Future Business is in"},"10":{"lid":"1587044866228","ls":"110","loff":"","li_type":"in","li_name":"What do you think you do the best","li_ph":"What do you think you do the best?","li_req":"y","li_nm":"What do you think you do the best"},"11":{"lid":"1587045181239","ls":"120","loff":"","li_type":"in","li_name":"What do you think others think you do the best","li_ph":"What do you think others think you do the best?","li_req":"y","li_nm":"What do you think others think you do the best"},"12":{"lid":"1587045222775","ls":"130","loff":"","li_type":"rd","li_name":"Your Current Income in USD","li_title":"Your Current Income in USD","li_req":"y","li_variants":"Less than 50k\n50k - 100k\n101k - 500k\nMore than 500k","li_radcb":"rb","li_nm":"Your Current Income in USD"},"13":{"lid":"1587045318191","ls":"140","loff":"","li_type":"in","li_name":"What do you expect to accomplish in this training","li_ph":"What do you expect to accomplish in this training?","li_req":"y","li_nm":"What do you expect to accomplish in this training"},"14":{"lid":"1587045361449","ls":"150","loff":"","li_type":"in","li_name":"Any previous efforts to make this change Yes or No. If Yes Results","li_ph":"Any previous efforts to make this change? Yes or No. If Yes, Results?","li_req":"y","li_nm":"Any previous efforts to make this change Yes or No. If Yes Results"},"15":{"lid":"1587045416829","ls":"160","loff":"","li_type":"ta","li_name":"How will you know you have succeeded in this training What are your benchmarks","li_ph":"How will you know you have succeeded in this training? What are your benchmarks?","li_req":"y","li_rows":"3","li_nm":"How will you know you have succeeded in this training What are your benchmarks"},"16":{"lid":"1587045539451","ls":"170","loff":"","li_type":"in","li_name":"Have you ever been treated for an emotional problem Yes No If Yes please explain:","li_ph":"Have you ever been treated for an emotional problem? Yes, No? If Yes, please explain:","li_req":"y","li_nm":"Have you ever been treated for an emotional problem Yes No If Yes please explain:"},"17":{"lid":"1587045628186","ls":"180","loff":"","li_type":"in","li_name":"How do you feel about your current situation Emotionally","li_ph":"How do you feel about your current situation? (Emotionally)","li_req":"y","li_nm":"How do you feel about your current situation Emotionally"},"18":{"lid":"1587045673413","ls":"190","loff":"","li_type":"sb","li_name":"How motivated are you to make changes in your current situation","li_title":"How motivated are you to make changes in your current situation?","li_req":"y","li_variants":"10\n9\n8\n7\n6\n5\n4\n3\n2\n1\n0","li_nm":"How motivated are you to make changes in your current situation"},"19":{"lid":"1587045726366","ls":"200","loff":"","li_type":"ta","li_name":"How do you think your life will be different after this training","li_ph":"How do you think your life will be different after this training?","li_req":"y","li_rows":"3","li_nm":"How do you think your life will be different after this training"},"20":{"lid":"1587046015450","ls":"210","loff":"","li_type":"in","li_name":"List three of your favorite colors:","li_ph":"List three of your favorite colors:","li_nm":"List three of your favorite colors:"},"21":{"lid":"1587046092415","ls":"220","loff":"","li_type":"in","li_name":"List three of your favorite places:","li_ph":"List three of your favorite places:","li_nm":"List three of your favorite places:"},"22":{"lid":"1587046111442","ls":"230","loff":"","li_type":"in","li_name":"List three of your favorite hobbies:","li_ph":"List three of your favorite hobbies:","li_nm":"List three of your favorite hobbies:"},"23":{"lid":"1587046130732","ls":"240","loff":"","li_type":"in","li_name":"List three of your favorite foods:","li_ph":"List three of your favorite foods:","li_nm":"List three of your favorite foods:"},"24":{"lid":"1587046145203","ls":"250","loff":"","li_type":"in","li_name":"List three of your favorite possessions:","li_ph":"List three of your favorite possessions:","li_nm":"List three of your favorite possessions:"},"25":{"lid":"1587046161474","ls":"260","loff":"","li_type":"in","li_name":"List three of your favorite movies:","li_ph":"List three of your favorite movies:","li_nm":"List three of your favorite movies:"},"26":{"lid":"1587046177491","ls":"270","loff":"","li_type":"in","li_name":"List three of your favorite friends:","li_ph":"List three of your favorite friends:","li_nm":"List three of your favorite friends:"},"27":{"lid":"1587046195700","ls":"280","loff":"","li_type":"ta","li_name":"List things that you would like to do better.","li_ph":"List things that you would like to do better.","li_req":"y","li_rows":"3","li_nm":"List things that you would like to do better."},"28":{"lid":"1587046264188","ls":"290","loff":"","li_type":"ta","li_ph":"List any worries or fears you have:","li_req":"y","li_rows":"2","li_nm":"Textarea_2"},"29":{"lid":"1587046297150","ls":"300","loff":"","li_type":"in","li_name":"If you could have it right now what would you wish for","li_ph":"If you could have it right now, what would you wish for?","li_req":"y","li_nm":"If you could have it right now what would you wish for"},"30":{"lid":"1587046323682","ls":"310","loff":"","li_type":"ta","li_name":"What were you afraid of in your childhood","li_ph":"What were you afraid of in your childhood?","li_req":"y","li_rows":"2","li_nm":"What were you afraid of in your childhood"},"31":{"lid":"1587046500981","ls":"320","loff":"","li_type":"in","li_name":"When you are learning something new do you prefer to look listen or do","li_ph":"When you are learning something new do you prefer to look, listen or do?","li_req":"y","li_nm":"When you are learning something new do you prefer to look listen or do"},"32":{"lid":"1587047315822","ls":"330","loff":"","li_type":"in","li_name":"What do you hate about others","li_ph":"What do you hate about others?","li_req":"y","li_nm":"What do you hate about others"},"33":{"lid":"1587047338680","ls":"340","loff":"","li_type":"in","li_name":"What are current triggers to anxiety or stress","li_ph":"What are current triggers to anxiety or stress?","li_req":"y","li_nm":"What are current triggers to anxiety or stress"},"34":{"lid":"1587047370070","ls":"350","loff":"","li_type":"in","li_name":"How do you soothe or calm yourself","li_ph":"How do you soothe or calm yourself?","li_req":"y","li_nm":"How do you soothe or calm yourself"},"35":{"lid":"1587047391601","ls":"360","loff":"","li_type":"in","li_name":"Where do you soothe or calm yourself","li_ph":"Where do you soothe or calm yourself?","li_req":"y","li_nm":"Where do you soothe or calm yourself"},"36":{"lid":"1587047444112","ls":"370","loff":"","li_type":"in","li_name":"How do you talk to yourself when you make a mistake","li_ph":"How do you talk to yourself when you make a mistake?","li_req":"y","li_nm":"How do you talk to yourself when you make a mistake"},"37":{"lid":"1587047470004","ls":"380","loff":"","li_type":"in","li_name":"I am the happiest when..","li_ph":"I am the happiest when..","li_req":"y","li_nm":"I am the happiest when.."},"38":{"lid":"1587047490805","ls":"390","loff":"","li_type":"in","li_name":"I feel guilty when..","li_ph":"I feel guilty when..","li_nm":"I feel guilty when.."},"39":{"lid":"1587047516544","ls":"400","loff":"","li_type":"in","li_name":"I feel angry when..","li_ph":"I feel angry when..","li_nm":"I feel angry when.."},"40":{"lid":"1587047527979","ls":"410","loff":"","li_type":"in","li_name":"I feel sad when..","li_ph":"I feel sad when..","li_nm":"I feel sad when.."},"41":{"lid":"1587047538592","ls":"420","loff":"","li_type":"in","li_name":"I feel scared when..","li_ph":"I feel scared when..","li_nm":"I feel scared when.."},"42":{"lid":"1587047559125","ls":"430","loff":"","li_type":"in","li_name":"What people think about you that isnt true","li_ph":"What people think about you that isnt true?","li_req":"y","li_nm":"What people think about you that isnt true"},"43":{"lid":"1587047599933","ls":"440","loff":"","li_type":"in","li_name":"What behaviors get in a way of your happiness","li_ph":"What behaviors get in a way of your happiness?","li_req":"y","li_nm":"What behaviors get in a way of your happiness"},"44":{"lid":"1587047634865","ls":"450","loff":"","li_type":"in","li_name":"What would you like to do more of","li_ph":"What would you like to do more of?","li_req":"y","li_nm":"What would you like to do more of"},"45":{"lid":"1587050191820","ls":"460","loff":"","li_type":"in","li_name":"What would you like to do less of","li_ph":"What would you like to do less of?","li_req":"y","li_nm":"What would you like to do less of"},"46":{"lid":"1587050706747","ls":"470","loff":"","li_type":"in","li_name":"What would you like to change about yourself","li_ph":"What would you like to change about yourself?","li_req":"y","li_nm":"What would you like to change about yourself"},"47":{"lid":"1587050746758","ls":"480","loff":"","li_type":"in","li_name":"What would you like to start or stop doing","li_ph":"What would you like to start or stop doing?","li_req":"y","li_nm":"What would you like to start or stop doing"},"48":{"lid":"1587050774182","ls":"490","loff":"","li_type":"in","li_name":"What are you proud of","li_ph":"What are you proud of?","li_req":"y","li_nm":"What are you proud of"},"49":{"lid":"1587050798671","ls":"500","loff":"","li_type":"in","li_name":"When you do something new do you prefer to be told what to do or figure it out yourself","li_ph":"When you do something new do you prefer to be told what to do or figure it out yourself?","li_req":"y","li_nm":"When you do something new do you prefer to be told what to do or figure it out yourself"},"50":{"lid":"1587050915316","ls":"510","loff":"","li_type":"in","li_name":"What do you appreciate the most in others","li_ph":"What do you appreciate the most in others?","li_req":"y","li_nm":"What do you appreciate the most in others"},"51":{"lid":"1587050945232","ls":"520","loff":"","li_type":"in","li_name":"What side of your character gets in a way to reach compromise in communications with others","li_ph":"What side of your character gets in a way to reach compromise in communications with others?","li_req":"y","li_nm":"What side of your character gets in a way to reach compromise in communications with others"},"52":{"lid":"1587050987229","ls":"530","loff":"","li_type":"in","li_name":"What is that you do better than anyone else you know","li_ph":"What is that you do better than anyone else you know?","li_req":"y","li_nm":"What is that you do better than anyone else you know"},"53":{"lid":"1587051050336","ls":"540","loff":"","li_type":"tx","li_text":"Mention your most significant memory, experience, or event that corresponds to each of these following periods of time in your life:"},"54":{"lid":"1587051169987","ls":"550","loff":"","li_type":"in","li_name":"0 - 5 years","li_ph":"0 - 5 years","li_req":"y","li_nm":"0 - 5 years"},"55":{"lid":"1587051193207","ls":"560","loff":"","li_type":"in","li_name":"6 - 10 years","li_ph":"6 - 10 years","li_req":"y","li_nm":"6 - 10 years"},"56":{"lid":"1587051212481","ls":"570","loff":"","li_type":"in","li_name":"11 - 15 years","li_ph":"11 - 15 years","li_req":"y","li_nm":"11 - 15 years"},"57":{"lid":"1587051228471","ls":"580","loff":"","li_type":"in","li_name":"16 - 20 years","li_ph":"16 - 20 years","li_req":"y","li_nm":"16 - 20 years"},"58":{"lid":"1587051242659","ls":"590","loff":"","li_type":"in","li_name":"21 - 30 years","li_ph":"21 - 30 years","li_req":"y","li_nm":"21 - 30 years"},"59":{"lid":"1587051256667","ls":"600","loff":"","li_type":"in","li_name":"31 - 40 years","li_ph":"31 - 40 years","li_req":"y","li_nm":"31 - 40 years"},"60":{"lid":"1587051271095","ls":"610","loff":"","li_type":"in","li_name":"41 - 50 years","li_ph":"41 - 50 years","li_req":"y","li_nm":"41 - 50 years"},"61":{"lid":"1587051286428","ls":"620","loff":"","li_type":"in","li_name":"51 - 60 years","li_ph":"51 - 60 years","li_req":"y","li_nm":"51 - 60 years"},"62":{"lid":"1587051190062","ls":"630","loff":"","li_type":"cb","li_req":"y","li_label":"I realize that Olena Pkhaladze is an educator, hypnotist, energist, and unconscious coach, not a medical doctor or psychologist, and that she cannot diagnose disease, prescribe, or treat medical conditions or serious disorders. I understand that the coaching and training I am receiving from Olena Pkhaladze is not a substitute for normal medical care and I have been advised to discuss this procedure with any doctor who is taking care of me now or in the future. Additionally, I should continue any present medical treatment and consult my regular physician for treatment of any new or old illnesses. I am willing to be guided through various methods, including relaxation, visual imagery, creative visualization, hypnosis, Neurolinguistic Programming (NLP), Emotional Freedom Techniques (EFT), and stress reduction processes for the purposes of vocational or avocational self-improvement. I also agree that Olena Pkhaladze or myself may terminate this relationship at any time for any reason whatsoever. I realize that although Olena Pkhaladzel has considerable training and many decades of experience, the training and insights she provides, are not a cure, and I accept that I am paying for her time, expertise, and insights, irrespective of any particular result. ","li_checked":"y","li_nm":"Checkbox"}}

Self-Made Heroes

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APPLICATION FORM