Sober Self Coaching Application Form
Break free from gray drinking patterns and discover your most authentic, confident self!
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Are you currently drinking alcohol 4+ days per week?
*
Yes
No
Do you consider yourself a "grey area drinker" - someone who drinks regularly but doesn't consider themselves an alcoholic?
Yes
No
Are you employed and financially stable?
*
Yes
No
Are you ready to commit 3-5 hours per week for 12 weeks to this transformation?
Yes
No
Have you been hospitalized or required medical detox for alcohol withdrawal?
Yes
No
How did you hear about this program?
Describe your current relationship with alcohol:How many days per week do you typically drink?How many drinks on a typical drinking day?What times of day do you usually drink?What triggers your drinking? (stress, boredom, social situations, etc.)
When did you first realize your drinking might be a problem?
What have you tried before to change your drinking habits?Moderation attemptsPrevious programs or therapyBooks, apps, or other resourcesWhat worked? What didn't work?
What is your biggest motivation for wanting to quit drinking?
Rate your commitment level on a scale of 1-10:
1-5: Not ready
6-7: Somewhat ready
8-10: Fully committed
What are you hoping to gain from an alcohol-free lifestyle?
Better sleep and energy
Improved relationships
Career advancement
Better physical health
Mental clarity
Reduced anxiety
Weight loss
Financial savings
Other: ________
What concerns do you have about quitting drinking?
Describe your typical evening routine:
How would you describe your stress levels and coping mechanisms?
Please Select
Very high stress, poor coping
Moderate stress, some healthy coping
Low stress, good coping strategies
Do you have support from family/friends for this change?
Please Select
Fully supportive
Somewhat supportive
Neutral/don't know
Unsupportive
Actively discouraging
What is your biggest obstacle to staying alcohol-free?
Social pressure
Stress management
Boredom
Partner/family dynamtics
Work events
Lack of alternatives
Emotional regulation
Other: ________
Why do you want to work with a coach versus trying to quit on your own?
Are you comfortable participating in group calls and online community?
Please Select
Yes, excited about community support
Yes, but somewhat nervous about sharing
Unsure
No, prefer private coaching only (not a fit)
Can you commit to: Attending monthly 90-minute group calls (Optional), Watching weekly video modules (Required), Completing weekly exercises and homework (Required), Participating in online community (Optional)
Please Select
Yes
No
Financial Commitment - Can you invest $2,997 in your transformation?
Please Select
Yes, full payment
Yes, with payment plan
Need scholarship consideration
Not at this time
Type a question
Why do you want to quit drinking?
example@example.com
What does success look like to you in 12 weeks?
Why should you be accepted into this program?
Submit
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