Application Form Group Transformative Experience (Malke a decision)

WowForward Unlimited FZCO

MAKE A DECISION

Application Form

All information is stricly confidential

Preferred Name and Surname *

Phone Number *

Email *

Confirmation Email example@example.com

From the time of your official registration, we will send you daily text reminders and questions we're expecting you to answer. This will allow us to ensure you are on track with the program and using it to the maximum of its capacity. We strongly advise you to accept our communication to happen by WhatsApp or Telegram. Please do let us know the fastest way to contact you daily: *

WhatsApp Telegram E-mail Other, please precise

Age *

Gender *

Marital Status *

Occupation *

Indicate your current challenges if any:

Are you currently under medication or following a treatment? *

YES NO

If yes, please give details below

History: Are there any illnesses or other concerns in your history that might be relevant ? *

YES NO

If yes, please give details below

Are you allergic or intolerant to anything? *

YES NO

If yes, please give details below

On a scale from 1 to 10 (10 being the most): how strongly is your fear of making decisions impacting your life ? *

Please give as many details as you feel like sharing below *

On a scale from 1 to 10 (10 being the strongest): how motivated are you to participate in this program and overcome your fear of making decisions? *

What do you do for fun?

DISCLAIMER: The information, techniques, methods and recommendations of any WowForward team member are not intended to replace the diagnosis and care of a qualified physician, psychiatrist or psychologist. Do not change the medication prescribed without your doctor's approval. If in doubt, you should seek medical advice. By participating in WowForward's Transformative Experience, you accept full responsibility for your own emotional and physical well-being and agree that WowForward Unlimited FZCO is not responsible for any negative outcome. By signing this form, I consent to WowForward disclosing information to a specific person or agency if it has been determined that I am an imminent danger to myself or others. *

I agree with the above disclaimer.

The information I have provided here is, to the best of my knowledge, complete and correct. I enter therapy with the understanding that it is a collaborative process and that progress depends in part on my own motivation and participation, including my willingness and desire to change within myself. If selected to participate, I will do so without the use of drugs or alcohol. *

I agree with the above.

Signature *

Clear

Date *