Application Form

1

Full Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Are you currently getting any support around relationships or attachment?

5

Are you currently in a relationship?

Yes

No

6

What makes this program right for you at this time?

7

What have you done already to work on this?

8

What would happen if you didn't work on your attachment right now?

9

Have you done any tests or processes to determine you have anxious attachment?

Yes

NO

10

Explain what if any...

11

Have you had any suicidal ideation?

Yes

NO

12

Explain what if any...

13

Are you currently in therapy?

Yes

NO

14

From Anxious to Secure is a 6 week program, that is self directed. It is packed with 25+ videos, worksheets and audios to help you accelerate your attachment work. Included are 3 months of group coaching calls (once a month) and access to a non-facebook private online community group. Your progress is directly correlated with how much effort you put in. Is this something you can dedicate at least an hour a week to?

Yes

NO

15

The program cost is currently $997, or 6 monthly payments of $197. Access is very limited, and the ongoing groups are kept on the smaller side to allow more support. The program includes lifetime access to the course materials, and any future additions or updates to the program, as well as any live versions that happen in the future. Are you able to afford this investment at this time?

Yes

No

16

Would you prefer the pay in full option or the payment schedule?

Pay in Full

Payments

17

Where do you want to be in a year from now?

18

Are there any questions you have for me at this time?