1 on 1 Coaching Application

Thank you for your interest in working together!

Please take a few minutes and answer the following questions.

Because of the demand, we are not able to accept all applicants into the program. 

We only have 3 spots available each month for our 1 on 1 program. 

This application is for serious inquiries only, so please only complete this application if you are serious + ready + willing to invest in one-on-one intensive coaching with me.

Click the button below to start.


Question 1 of 21

What is Your Name?

Question 2 of 21

What is your age?

Question 3 of 21

Where are you located (City & State) and Timezone

Question 4 of 21

What is Your Email Address?

Question 5 of 21

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


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


Question 6 of 21

May I contact you via text message?





Question 7 of 21

Please tell us about your current experience with OCD & Anxiety. Please describe the ways this is impacting or limiting important areas of your life.

Question 8 of 21

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 9 of 21

On a Scale of 1 - 10 - How important is 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 10 of 21

In TBC, one of our top priorities is to create an amazing environment that will support our members and help them achieve their goals. Part of that is making sure we deliver an amazing experience for you...Another part is making sure those who attend bring positive and supportive energy to the community. Please describe the positive traits you possess that you will bring to the community.

Question 11 of 21

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 12 of 21

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


If yes, can you please explain?

Question 13 of 21

What other products, programs, or services have you taken or invested in regarding OCD & Anxiety?

Question 14 of 21

Have you purchased any Restored Minds products, programs, courses, or services?





Question 15 of 21

If yes, thank you! Please list the products you have purchased or participated in:

Question 16 of 21

Please tell us why you are interested in joining Taking Back Control?

Question 17 of 21

What hesitations or fears do you have about joining Taking Back Control? 

Question 18 of 21

Do you believe that investing in the proper coaching and training will create better results for you?





Question 19 of 21

During the application process, our team will be in contact with you to discuss all of your questions including the financial investment for the program.


Each coaching program is customized to best meet the needs of each individual.

Are you willing to invest in yourself when it comes to addressing OCD & Anxiety?







Question 20 of 21

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

Question 21 of 21

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

Confirm and Submit