application

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
Confirm Email
3
Where are you from?* This field is required.
United Kingdom
United States
Ireland
Canada
Germany
Other
4
In a few words, how have you been affected by Narcissistic Abuse?* This field is required.
0/500
5
Please tell us a little bit about the you before the Narcissistic Abuse* This field is required.
0/250
6
Are you currently in No Contact with the Narcissist?* This field is required.
Yes! All blocked and deleted
We're not talking but I still have his number/email/social media, just in case
Modified contact
We are in touch regularly
7
If you ticked "Modified Contact", "We are in touch regularly" or "Other", please explain your situation in a few words
0/250
8
What has been the impact of Narcissistic Abuse on all different aspects of your life? * This field is required.(work, relationships, quality of life etc.)
0/250
9
Which of these symptoms are you experiencing?* This field is required.Please rate on a scale from 0 (not at all) to 10 (all the time)
Anxiety
Depression
Flashbacks
Nightmares
Loss of Identity
Sense of Worthlessness
Difficult to control emotions (such as anger & sadness)
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10
Anxiety
Depression
Flashbacks
Nightmares
Loss of Identity
Sense of Worthlessness
Difficult to control emotions (such as anger & sadness)
0
1
2
3
4
5
6
7
8
9
10
0
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10
What other symptoms are you experiencing which are not listed?
0/100
11
What outcome would you like to achieve as a result of attending Roni's award-winning Road to Recover Me® Kickstart Program?* This field is required.Please be really specific!
0/250
12
What expectations do you have of both Roni as your coach and this program?* This field is required.
0/250
13
How willing are you to invest in yourself and your own well-being?* This field is required.
14
I have the time to invest in myself* This field is required.
YESNO
15
I have the money to invest in myself* This field is required.
YESNO
16
I can make and keep appointments with myself to work on this * This field is required.
YESNO
17
I am fully willing to do the work required to get me where I want to go * This field is required.
YESNO
18
I am willing to stop or change the self-defeating behaviours that limit my success * This field is required.
YESNO
19
I am willing to try new things even if I am not 100% convinced they will work* This field is required.
YESNO
20
I have the patience to take consistent action towards my goals, regardless of how immediate the results are* This field is required.
YESNO
21
How important is it for you to heal from this?* This field is required.
I don't really care
Healing is my no.1 priority!
22
How committed are you to making this happen?
Whatever
Absolutely, whatever it takes!
23
What tools, approaches and methodologies have you explored to recover from Narcissistic Abuse?* This field is required.
0/100
24
If you've explored therapy and other intervention methods before, what has been your biggest frustration?
25
Are there any medical conditions or requirements on your part that are likely to affect your capability to participate and/or we would benefit from being aware of? (consent letter from GP may be requested)* This field is required.
Yes
No
Maybe
26
If you ticked "yes or Maybe", which condition(s) are you referring to?
0/100
27
I am psychologically sound and know of no reason (medical, psychological or otherwise) why I should not undertake this program and I am not taking any prescribed medication that could adversely impact the treatment, nor am I seeing a counsellor or therapist. (consent letter from GP may be requested)* This field is required.
YESNO
28
Have you seen a psychiatrist in the last 12 months?* This field is required.
YESNO
29
Is there anything else you would like to add to support your application?
30
* This field is required.
Should be Empty: