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Taking Back Control Coaching Application

Please complete the following 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

May I contact you via text message?

A

Yes

B

No

Question 7 of 17

Where are you located (City & State) and Timezone

Question 8 of 17

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

Question 9 of 17

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

A

Mild

B

Moderate

C

Severe

D

Extreme

Question 10 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 11 of 17

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

Question 12 of 17

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 13 of 17

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

 

If yes, can you please explain?

Question 14 of 17

How did you hear about Restored Minds?

A

Youtube

B

Podcast

C

Referral

D

Other

Question 15 of 17

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

Question 16 of 17

Are you able to invest in coaching services?

Question 17 of 17

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

Confirm and Submit