You can always press Enter⏎ to continue
Road To Recover Me® - Kickstart Program
Award-winning Narcissistic Abuse Recovery Coaching
Apply NOW
1
Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Email
*
This field is required.
example@example.com
Confirm Email
Previous
Next
Submit
Press
Enter
3
Where are you from?
*
This field is required.
United Kingdom
United States
Ireland
Canada
Germany
Other
United Kingdom
United States
Ireland
Canada
Germany
Other
Previous
Next
Submit
Press
Enter
4
In a few words, how have you been affected by Narcissistic Abuse?
*
This field is required.
0/500
Previous
Next
Submit
Press
Enter
5
Please tell us a little bit about the you before the Narcissistic Abuse
*
This field is required.
0/250
Previous
Next
Submit
Press
Enter
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
Other
Previous
Next
Submit
Press
Enter
7
If you ticked "Modified Contact", "We are in touch regularly" or "Other", please explain your situation in a few words
0/250
Previous
Next
Submit
Press
Enter
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
Previous
Next
Submit
Press
Enter
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)
0
1
2
3
4
5
6
7
8
9
10
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
Row 0, Column 11
0
1
2
3
4
5
6
7
8
9
10
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Row 1, Column 7
Row 1, Column 8
Row 1, Column 9
Row 1, Column 10
Row 1, Column 11
0
1
2
3
4
5
6
7
8
9
10
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Row 2, Column 7
Row 2, Column 8
Row 2, Column 9
Row 2, Column 10
Row 2, Column 11
0
1
2
3
4
5
6
7
8
9
10
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
Row 3, Column 7
Row 3, Column 8
Row 3, Column 9
Row 3, Column 10
Row 3, Column 11
0
1
2
3
4
5
6
7
8
9
10
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Row 4, Column 7
Row 4, Column 8
Row 4, Column 9
Row 4, Column 10
Row 4, Column 11
0
1
2
3
4
5
6
7
8
9
10
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
Row 5, Column 7
Row 5, Column 8
Row 5, Column 9
Row 5, Column 10
Row 5, Column 11
0
1
2
3
4
5
6
7
8
9
10
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Row 6, Column 6
Row 6, Column 7
Row 6, Column 8
Row 6, Column 9
Row 6, Column 10
Row 6, Column 11
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
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
Row 0, Column 11
0
1
2
3
4
5
6
7
8
9
10
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Row 1, Column 7
Row 1, Column 8
Row 1, Column 9
Row 1, Column 10
Row 1, Column 11
0
1
2
3
4
5
6
7
8
9
10
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Row 2, Column 7
Row 2, Column 8
Row 2, Column 9
Row 2, Column 10
Row 2, Column 11
0
1
2
3
4
5
6
7
8
9
10
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
Row 3, Column 7
Row 3, Column 8
Row 3, Column 9
Row 3, Column 10
Row 3, Column 11
0
1
2
3
4
5
6
7
8
9
10
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Row 4, Column 7
Row 4, Column 8
Row 4, Column 9
Row 4, Column 10
Row 4, Column 11
0
1
2
3
4
5
6
7
8
9
10
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Row 5, Column 5
Row 5, Column 6
Row 5, Column 7
Row 5, Column 8
Row 5, Column 9
Row 5, Column 10
Row 5, Column 11
0
1
2
3
4
5
6
7
8
9
10
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Row 6, Column 5
Row 6, Column 6
Row 6, Column 7
Row 6, Column 8
Row 6, Column 9
Row 6, Column 10
Row 6, Column 11
Previous
Next
Submit
Press
Enter
10
What other symptoms are you experiencing which are not listed?
0/100
Previous
Next
Submit
Press
Enter
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
Previous
Next
Submit
Press
Enter
12
What expectations do you have of both Roni as your coach and this program?
*
This field is required.
0/250
Previous
Next
Submit
Press
Enter
13
How willing are you to invest in yourself and your own well-being?
*
This field is required.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Previous
Next
Submit
Press
Enter
14
I have the time to invest in myself
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
15
I have the money to invest in myself
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
16
I can make and keep appointments with myself to work on this
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
17
I am fully willing to do the work required to get me where I want to go
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
18
I am willing to stop or change the self-defeating behaviours that limit my success
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
19
I am willing to try new things even if I am not 100% convinced they will work
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
20
I have the patience to take consistent action towards my goals, regardless of how immediate the results are
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
21
How important is it for you to heal from this?
*
This field is required.
1
2
3
4
5
I don't really care
Healing is my no.1 priority!
Previous
Next
Submit
Press
Enter
22
How committed are you to making this happen?
1
2
3
4
5
Whatever
Absolutely, whatever it takes!
Previous
Next
Submit
Press
Enter
23
What tools, approaches and methodologies have you explored to recover from Narcissistic Abuse?
*
This field is required.
0/100
Previous
Next
Submit
Press
Enter
24
If you've explored therapy and other intervention methods before, what has been your biggest frustration?
Previous
Next
Submit
Press
Enter
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
Previous
Next
Submit
Press
Enter
26
If you ticked "yes or Maybe", which condition(s) are you referring to?
0/100
Previous
Next
Submit
Press
Enter
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.
YES
NO
Previous
Next
Submit
Press
Enter
28
Have you seen a psychiatrist in the last 12 months?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
29
Is there anything else you would like to add to support your application?
Previous
Next
Submit
Press
Enter
30
*
This field is required.
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
30
See All
Go Back
Submit
%20(2).5ff0455aed8e33.22261248.png){kind=logo}