First Name

Last Name

Phone *

Are you looking for help conquering anxiety or other similar/related mental health issues (fear, self-doubt, overthinking...)?

Yes!

No.

What are the biggest issues you're looking for help solving?

Debilitating anxiety.

Overthinking and catastrophizing.

Self-doubt and self-esteem issues.

People pleasing and unhealthy boundaries.

Focus, productivity and executive funcitioning issues.

Lack of motivation.

General fear, dread and a uneasy feeling.

(OPTIONAL) Tell me a bit more about what you're dealing with and how it's affecting your life and/or career.

Which of the following best describes your financial situation? *

I have resources easily available and on hand to invest in a solution to my anxiety that I truly believe in.

I’m living paycheck-to-paycheck, so getting funds together might be a challenge, but I'm willing to try to find a way if I believe I've found a solution to my anxiety.

Money is a constant source of stress - I don’t have any funds or credit at all, and I’m willing to keep living with my anxiety.

Last question: How soon are you committed to make this change? *

RIGHT NOW - I want to get started immediately.

WITHIN 90 DAYS - I have other things to attend to first.

MORE THAN 90 DAYS - I want to do this eventually but I’m not sure when.

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