1:1 Application Form
Please fill out the form below. This helps me understand a little more about you. Once the form is submitted, I will get back to you within 48 hours via WhatsApp. If you'd prefer to chat before completing this form, please reach out to me via Instagram or TikTok — @wordsofamber
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number (Please include country code & area code. I will use this to contact you on Whatsapp.)
*
Social Media handle (Instagram/Tiktok)
*
Age
*
What are you currently struggling with the most? (Panic attacks, health anxiety, constant overthinking, burnout, fight-or-flight etc.)
*
How long has this been affecting you?
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Less than 6 months
6-12 months
1-3 years
3+ years
How is anxiety currently impacting your life?
*
What have you already tried? (Therapy, medication, self-help etc)
*
This is a private service, are you prepared to invest in the cost of the programme?
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Yes
No
Just exploring options
Once you submit this form, I will reach out to you via WhatsApp. The next steps will be to have a small chat and then from there book a Zoom call. Are you comfortable with a Zoom call?
*
Yes
No
Thank you so much, I will get back to you within 48 hours. I look forward to speaking with you more. 🤍
Submit
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