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Taking Back Control Coaching Application

Please complete the following questions.

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Question 1 of 14

What is Your Name?

Question 2 of 14

What is Your Email Address?

Question 3 of 14

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 4 of 14

May I contact you via text message?

A

Yes

B

No

Question 5 of 14

What is your age?

Question 6 of 14

What is your location (City & State) and Timezone

Question 7 of 14

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

Question 8 of 14

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

A

Mild

B

Moderate

C

Severe

D

Extreme

Question 9 of 14

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

Question 10 of 14

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 11 of 14

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

 

If yes, can you please explain?

Question 12 of 14

What are your preferred times for coaching calls?

A

Morning

B

Afternoon

C

Evening

D

Anytime

Question 13 of 14

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

Question 14 of 14

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

Confirm and Submit