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Taking Back Control Coaching Application

Please Complete The Follow Questions

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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?

A

Yes

B

No

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?

A

Mild symptoms / very little impact on my life and functioning

B

Moderate symptoms / moderate impact on my life and functioning

C

Severe symptoms / significant impact on my life and functioning

D

Extreme symptoms / Extreme impact on my life and ability to function

Question 10 of 17

On a Scale of 1 - 10 - How bad do you want this right now? (10 Being your highest level of desire to show up for yourself, 1 being the lowest) 

Question 11 of 17

The Taking Back Control Program is a life-changing investment in yourself and your long-term well-being and personal growth. Please share about your willingness & your ability to invest in yourself at the present moment.

Question 12 of 17

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 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

How did you hear about Restored Minds?

A

Youtube

B

Podcast

C

Referral

D

Other

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?

Confirm and Submit