The Speakeasy Focus Form Name* : Email* : Age* : How did you hear of me* : Address* : Industry* : Why Reach Out?* Have you ever failed before - care to explain?* Did it define you or refine you?* Does the truth hurt? YesNo Frightened of doing the heavy lifting? YesNo What are you hoping will happen during our relationship?* Please list 3 things you would like to focus on : 1 . 2 . 3 . By using this form you agree with the storage and handling of your data by this website.