Agoraphobia Exposure - Initial Questionnaire

Please fill in this form before booking our chat.

The purpose of this form is so that I can know a bit about you, and we can dive right in and make the most of our time on the day.

During our chat we'll talk about your agoraphobia and how exposure works.

I'll also talk about the coaching so that we can decide if it could benefit you.

* At the end you'll be able to save a PDF of this form with all your answers.

* If you don't already have the link to book an appointment, hold down CONTROL first and then click HERE.

* Do not refresh this page otherwise you'll lose all your answers.

* Be sure to read every question very carefully.

SUITABILITY FOR THIS COACHING

If after our conversation you decide to go ahead with this coaching, please note that I can only work with those who are a good match.

With that in mind, please tick the boxes below to confirm that ALL of the following apply to you, in the event that you decide to do the coaching.

If you were to work with me (ALL of the following must apply to you, otherwise I cannot help you - please read carefully) :

Our initial chat is free and no-obligation, however please note that the price of the coaching, if you do decide that it is for you, is $10,000.

YOUR DETAILS :

Please fill in your name (surname is optional) and your best email address :

How did you find out about Agoraphobia Exposure?

Other

ABOUT YOUR AGORAPHOBIA :

This section is for you to tell me a bit about the issues you're having.

Don't feel like you have to give long answers, just tell me enough so that I understand the nature of your agoraphobia.

The text boxes will allow you to write as much as you need to.

When, where and how did your agoraphobia start? What was the first thing that triggered it?

Is there any underlying issue in your life that you think had something to do with it?

How long have you had agoraphobia, and roughly how many anxious moments or panic attacks have you had and/or how often does it happen?

When was the last time you panicked or had anxiety, and how bad was it?

When you have anxiety or a panic attack, how bad is it usually, and what's the worst you've had?

Do you have any other issues (i.e. OCD, social anxiety, phobias) that may make the agoraphobia worse?

ABOUT THE FUTURE :

What would your life be like if you were to never overcome your agoraphobia, and how would you feel?

What kinds of things would you like to be able to do in life if you were free of agoraphobia?

If this coaching is suitable for you, what would you hope to get out of it? And what would you want from me as a coach?

ANYTHING ELSE :

Let me know if there's anything else you’d like to add.

WHAT HAPPENS NEXT :

* Do not refresh this page otherwise you'll lose all your answers.

* Please read all of these steps first and then follow them carefully.

1) Click on Review Answers (below).

2) After reviewing your answers, click on Review Answers again and scroll down to the bottom of the page.

Once all the required questions are answered you'll see Print and Submit (Don't submit yet!)

3) Do this before submitting this form : Save your answers by clicking on Print, then next to Destination use the drop down menu and select Save As PDF.

4) Click on Submit

5) Book an appointment with me (Hold down CONTROL first then click HERE), and close this tab.

Thank you, and I look forward to chatting with you soon!