Rise Unlimited™ Application

1
What is your full name?* This field is required.
First Name
Last Name
2
What is your best email address?* This field is required.
example@example.com
Confirm Email
3
What is the best phone number to reach you?* This field is required.Include country code if outside the U.S. Phone or WhatsApp is fine.
4
What do you do for work?* This field is required.
5
Before we go further, have you already checked with a doctor and ruled out anything medical behind these symptoms?* This field is required.
Yes, I have already ruled out anything medical
I am in the process of checking that now
No, I have not done that yet
6
In your own words, what symptoms have you been experiencing?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
7
How long have you been dealing with these symptoms?* This field is required.
Less than 30 days
1 to 6 months
6 to 12 months
1 to 3 years
3 to 5 years
5 years+
8
How much is this affecting your life right now?* This field is required.
It is hard, but I can still function fairly well
It disrupts parts of my life and some days are much harder than others
It is holding me back in important areas like work, relationships, or daily functioning
It feels overwhelming and I need real support now
9
What have you already tried to get better? Select all that apply.* This field is required.
Distraction
Acceptance
Talk therapy
CBT
Medication
Breathing exercises or meditation
Somatic work
Exposure work
Online courses or programs
Religious or spiritual counseling
Nothing structured yet
Other
10
What are you most afraid will happen if nothing changes in the next 6 to 12 months?* This field is required.
11
How urgent is it for you to solve this now?* This field is required.
I know I need to deal with it, but I am not in a rush yet
I want to improve soon, but I am still exploring options
I need help now and I am ready to take action immediately if this is the right fit
12
How confident are you that Coach Jordan Hardgrave is the right person to help you recover?* This field is required.
I'm still not sure if he's the right person to help me recover
I believe he could help me recover, but I still have some questions
I'm confident he's the right person to help me recover
13
How familiar are you with Jordan's content and recovery approach?* This field is required.
I am very new and have only recently come across his content
I have watched a few of his videos and have a basic sense of his approach
I have followed his content for a while and understand his recovery approach fairly well
14
If this feels like the right fit, what is your financial situation right now?* This field is required.
I'm not in a position to invest right now and am only looking for free help
Money is tight, but I'd consider options if this feels like the right fit
I could make this work if I believe this is the right next step
I'm financially ready to move forward if this is the right fit
15
If mentorship feels like the right fit and we determine that we can help you, are you in a position to make that decision and access the resources needed to move forward?* This field is required.
Yes, I can make that decision and access the resources on my own
I would need to talk it through with my spouse or partner first
I would need support from someone else to access the resources
16
I understand that if I book a call and no-show without notice, I may lose the opportunity to apply again in the future.* This field is required.
Yes, I understand
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