Please Complete The Follow Questions
Click the button below to start.
Question 1 of 17
What is Your Name?
Question 2 of 17
What is your age?
Question 3 of 17
What is Your Email Address?
Question 4 of 17
If you live in the United States please provide your phone number.
Question 5 of 17
If you live outside of the United States please provide your WhatsApp contact number.
Question 6 of 17
Where are you located (City & State) and Timezone
Question 7 of 17
May I contact you via text message?
Question 8 of 17
In a few paragraphs, please describe your current experience with OCD & Anxiety. Please describe the ways this is impacting or limiting important areas of your life?
Question 9 of 17
How would you describe the severity of the OCD & Anxiety symptoms you are experiencing and how much are they impacting your life and daily functioning?
Mild symptoms / very little impact on my life and functioning
Moderate symptoms / moderate impact on my life and functioning
Severe symptoms / significant impact on my life and functioning
Extreme symptoms / Extreme impact on my life and ability to function
Question 10 of 17
On a Scale of 1 - 10 - How important is this taking your life back from OCD & Anxiety right now? (10 Being your highest level of desire to show up for yourself, 1 being the lowest)
Question 11 of 17
The TBC Coaching Program is a high-ticket investment, both in yourself and your long-term well-being. Are you in a place where you are willing and able to invest in yourself?
Question 12 of 17
Which program are you most interested in?
Taking Back Control PLUS+ (Our Group Coaching Program)
Taking Back Control Intensive Coaching (Our 1 on 1 Coaching Program)
Question 13 of 17
Have you been diagnosed with any other mental health conditions? If yes, can you please list them below? (This will only be reviewed by myself and my admissions director)
Question 14 of 17
Have you ever been hospitalized for any suicidal attempts or other mental health conditions?
If yes, can you please explain?
Question 15 of 17
Can you please share how you discovered Restored Minds?
Question 16 of 17
If accepted to the program, how soon could you get started?
Question 17 of 17
Is there anything else we should know when reviewing your application?