Welcome to Your Coaching Application
I appreciate your interest in coaching with Healing Recipes Ltd. This form helps us understand your goals, expectations, and whether coaching is the right fit for you. Please fill in the required details honestly.
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Personal Information
Name
*
First Name
Last Name
Date of birth
*
/
Day
/
Month
Year
Date
Email
*
example@example.com
Country/Time Zone
*
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Service Selection
Which coaching service are you interested in?
*
Please Select
Breaking free from DPDR
Emotional Resilience & Self-Discovery
Mindset & Thought Reframing
Navigating Relationships & Boundaries
Which coaching option are you interested in
*
Single 1:1 Coaching Session (£50)
Package of 3 Sessions (£120)
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Age:
(Must be
18+
to apply)
*
18 - 24
25 - 34
35 - 44
45+
Do you experience hallucinations, Suicidal thoughts or self harm?
*
Yes
No
What are your main DPDR symptoms?
(Check all that apply)
*
Feeling disconnected from reality (derealization)
Feeling detached from yourself (depersonalization)
Emotional numbness
Foggy or dreamlike perception
Memory or concentration difficulties
Feeling like you are ‘going crazy’
Anxiety or panic related to DPDR
Other (Please specify here)
Have you been officially diagnosed with any mental health condition?
(Diagnosis is NOT required.)
*
No, I have not been diagnosed
Yes (please specify here)
Are you currently in therapy or receiving treatment for DPDR or other mental health conditions?
*
Yes
No
What have you tried so far to manage DPDR? (Check all that apply)
*
The DP Manual
Therapy
Medication
Researching DPDR
Meditation/Breathing exercises
Avoidance/Nothing
Other
How do you currently cope when DPDR feels overwhelming?
*
What are your main struggles when dealing with DPDR?
*
What do you hope to gain from this coaching?
*
Coaching Readiness & Fit
Imagine you’re feeling a strong wave of DPDR symptoms right now. What is the FIRST thing you would do?
*
Are you ready to take action and apply what you learn in coaching?
*
Yes, I am ready to commit to the process.
No, I am unsure if I can apply what I learn.
What motivates you to work on your DPDR recovery?
*
I want to feel connected to my life and emotions again.
I want to reduce anxiety and fear around DPDR.
I want to be able to enjoy everyday activities without feeling detached.
I want to build stronger relationships and feel present with loved ones.
I want to regain my focus and mental clarity to work/study.
Other (Specify here)
How has DPDR affected your life?
*
Acknowledgment & Agreement
Please read carefully and agree before submitting.
Acknowledgment & Agreement
*
Rows
Yes
No
I understand that this coaching is NOT therapy or a substitute for professional mental health treatment.
I acknowledge that specific results are NOT guaranteed, and my recovery depends on my efforts and personal circumstances.
I take full responsibility for my own progress and understand that Lujain is providing coaching based on personal experience, not as a licensed therapist.
I am emotionally stable enough to participate in coaching and will seek professional help if needed.
I confirm that all the information I provided is accurate, and I agree to enroll in this free coaching giveaway under these conditions.
Please sign below
*
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What led you to seek coaching?
*
What specific challenges are you facing in this area?
*
Have you tried anything before to work on this issue?
*
What are you hoping to gain from coaching?
*
How committed are you to making changes?
*
Not Very
1
2
3
4
Fully
5
1 is Not Very, 5 is Fully
Do you understand that coaching is NOT therapy?
*
I understand and Agree
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Final Agreement & Consent
*
I understand that coaching is not therapy, counseling, or medical treatment.
I understand that results depend on my own effort and commitment.
I have read and agree to the coaching terms, cancellation policies, and privacy policy.
Signature
*
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Final Step: Submit Your Application
Thank you for completing your application. Please review your details to ensure accuracy before submitting. Once received, we will carefully review your responses and contact you via email if your application is approved. Please allow some time for us to get back to you. Click Submit to complete your application.
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