4WMDR Feedback Registration Form
Take my new 4 Week Mindful drinking Reset for free and feedback on the good, the bad and the ugly.
About You
Name
First Name
Last Name
Email
example@example.com
Age
Occupation
Country of residence
About the Reset
What is going on in your life that makes you want to take part in this reset right now?
Are you currently looking to...
Reduce your overall alcohol intake
Moderate when you socialise
Learn more about mindful drinking to see if it suits you
Remove alcohol altogether
Other
On average, how frequently do you drink?
Most days
A few times a week
Just on weekends/special occasions
Hardly at all
Have you tried to moderate your drinking in the past, either alone or with support? If yes, what did you try (friends, family, books, courses, professional help, etc) and what was the biggest hurdle?
Your commitment
Can you commit to reading a short daily email and completing the reflection task every day for 4 weeks? (around 5-10 minutes a day max)
Yes
No
Do you agree to send a weekly email/complete a survey sharing your detailed feedback on the content of the Reset for that week and overall?
Yes
No
Are you happy to provide a testimonial at the end of the Reset about how the experience has been for you?
Yes
No
Submit
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