QbH Coaching Application Form

1

Name* This field is required.What should I call you?

2

How old are you?* This field is required.

3

How many years have you been together with your current partner?* This field is required.

4

For how many years have you been using pornography on a regular basis?* This field is required.

5

What have you tried so far to overcome your addiction?Any strategies you have tried so far like following NoFap, therapy or similar. Leave blank if nothing comes to mind.

6

What is the main problem porn use is causing in your relationship?* This field is required.

7

What is the best thing that this coaching could do for you?* This field is required.Ideal case, what is the outcome you want to achieve through working with me?

8

Email* This field is required.Type an email address where I can reach you

example@example.com