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Taking Back Control Coaching Application

Please complete the following questions.

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Question 1 of 15

What is Your Name?

Question 2 of 15

What is your age?

Question 3 of 15

What is Your Email Address?

Question 4 of 15

If you live in the United States please provide your phone number

 

If you live outside of the United States please provide your WhatsApp number

Question 5 of 15

May I contact you via text message?

A

Yes

B

No

Question 6 of 15

Where are you located (City & State) and Timezone

Question 7 of 15

In a few paragraphs, please describe your current experience with OCD & Anxiety-Related Disorders?

Question 8 of 15

How much is OCD & Anxiety currently impacting your life and daily functioning?

A

Mild

B

Moderate

C

Severe

D

Extreme

Question 9 of 15

Which program are you most interested in?

A

Taking Back Control (Our Self-Study Program)

B

Taking Back Control PLUS+ (Our Group Coaching Program)

C

Taking Back Control Intensive Coaching (Our 1 on 1 Coaching Program)

Question 10 of 15

How would you describe your motivation for treatment on a scale of 1-10? (1 = not motivate, 10 = Extremely motivated)

Question 11 of 15

Have you been diagnosed with any other conditions? If yes, can you please list them below? (This will only be reviewed by myself and my admissions director)

Question 12 of 15

Have you ever been hospitalized for any suicidal attempts or other mental health conditions?

 

If yes, can you please explain?

Question 13 of 15

How did you hear about Restored Minds?

A

Youtube

B

Podcast

C

Referral

D

Other

Question 14 of 15

If accepted to the program, how soon could you get started?

Question 15 of 15

Is there anything else we should know when reviewing your application?

Confirm and Submit