Once you have completed this form, you will be contacted by Emma within 24 hours.
Email*
Valid email
This form is collecting emails.Change settings
Full Name
*
Question
Full Name
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Short answer text
Response validation has been added.
Remove
Number
Text
Length
Regular expression
Greater than
Greater than or equal to
Less than
Less than or equal to
Equal to
Not equal to
Between
Not between
Is number
Whole number
Number
and
Number
Custom error text
Answer key
(0 points)
Loading...
Loading…
Timezone
*
Question
Timezone
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Short answer text
Response validation has been added.
Remove
Number
Text
Length
Regular expression
Greater than
Greater than or equal to
Less than
Less than or equal to
Equal to
Not equal to
Between
Not between
Is number
Whole number
Number
and
Number
Custom error text
Answer key
(0 points)
Loading...
Loading…
Recovery coaching is only available to those who are aged 25 years old or above. Please confirm that you are aged 25 years old or above.
*
Question
Recovery coaching is only available to those who are aged 25 years old or above. Please confirm that you are aged 25 years old or above.
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
I confirm that I am aged 25 years or above.
Other:
Add option
or
add "Other"
…
Select at least
Select at most
Select exactly
Number
Custom error text
Answer key
(0 points)
Loading...
Loading…
Why would you like to work with me?
*
Question
Why would you like to work with me?
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Long answer text
Length
Regular expression
Maximum character count
Minimum character count
Number
Custom error text
Answer key
(0 points)
Loading...
Loading…
Please describe your current situation and what you struggle with the most.
*
Question
Please describe your current situation and what you struggle with the most.
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Long answer text
Length
Regular expression
Maximum character count
Minimum character count
Number
Custom error text
Answer key
(0 points)
Loading...
Loading…
Please briefly describe what your ideal life would look like if you were to achieve a full recovery.
*
Question
Please briefly describe what your ideal life would look like if you were to achieve a full recovery.
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Long answer text
Length
Regular expression
Maximum character count
Minimum character count
Number
Custom error text
Answer key
(0 points)
Loading...
Loading…
Are you 100% committed to putting in the time, focus, and action that’s necessary to make your vision of a full recovery possible?
*
Question
Are you 100% committed to putting in the time, focus, and action that’s necessary to make your vision of a full recovery possible?
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Yes
No
Other:
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Loading…
If we get on a discovery call and identify as a good fit to work together, then are you willing to make the investment in yourself to hire me as your coach?
*
Question
If we get on a discovery call and identify as a good fit to work together, then are you willing to make the investment in yourself to hire me as your coach?
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Yes
No
Other:
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Loading…
How did you discover B-Free Recovery?
*
Question
How did you discover B-Free Recovery?
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
Short answer text
Response validation has been added.
Remove
Number
Text
Length
Regular expression
Greater than
Greater than or equal to
Less than
Less than or equal to
Equal to
Not equal to
Between
Not between
Is number
Whole number
Number
and
Number
Custom error text
Answer key
(0 points)
Loading...
Loading…
Please confirm the following. 1) I understand that B-Free Recovery coaching cannot provide medical treatment or diagnosis. 2) I understand that this program is not meant to diagnose, treat, or prevent any disease or illness. 3) I understand that I am responsible for my own health at all times, and I am advised and expected to use any coaching in conjunction (not in lieu of) with professional medical advice. 4) I understand that with any changes in lifestyle, there are certain risks involved, and I take full responsibility for my health and my choices.
*
Question
Please confirm the following. 1) I understand that B-Free Recovery coaching cannot provide medical treatment or diagnosis. 2) I understand that this program is not meant to diagnose, treat, or prevent any disease or illness. 3) I understand that I am responsible for my own health at all times, and I am advised and expected to use any coaching in conjunction (not in lieu of) with professional medical advice. 4) I understand that with any changes in lifestyle, there are certain risks involved, and I take full responsibility for my health and my choices.
*
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
New
Multiple choice grid
Checkbox grid
Date
Time
Description
Loading image…
Caption
I confirm.
Other:
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Loading…
Link to Sheets
The number of responses collected by this form may exceed the limit supported by Sheets. If you're having trouble viewing your responses in Sheets, try downloading a .CSV instead.
Message for respondents
This form is no longer accepting responses
Summary
Question
Individual
Insights
Total points distribution
Loading...
Loading responses…
This form is approaching the response limit. Once surpassed, the summary of responses will no longer be displayed. Learn more
Close
This form has exceeded 50,000 responses and the summary of responses can no longer be displayed. You can still download responses as a .csv file. Learn more
Full Name
Copy chart
No responses yet for this question.
Timezone
Copy chart
No responses yet for this question.
Recovery coaching is only available to those who are aged 25 years old or above. Please confirm that you are aged 25 years old or above.
Copy chart
No responses yet for this question.
Why would you like to work with me?
No responses yet for this question.
Please describe your current situation and what you struggle with the most.
No responses yet for this question.
Please briefly describe what your ideal life would look like if you were to achieve a full recovery.
No responses yet for this question.
Are you 100% committed to putting in the time, focus, and action that’s necessary to make your vision of a full recovery possible?
Copy chart
No responses yet for this question.
If we get on a discovery call and identify as a good fit to work together, then are you willing to make the investment in yourself to hire me as your coach?
Copy chart
No responses yet for this question.
How did you discover B-Free Recovery?
Copy chart
No responses yet for this question.
Please confirm the following. 1) I understand that B-Free Recovery coaching cannot provide medical treatment or diagnosis. 2) I understand that this program is not meant to diagnose, treat, or prevent any disease or illness. 3) I understand that I am responsible for my own health at all times, and I am advised and expected to use any coaching in conjunction (not in lieu of) with professional medical advice. 4) I understand that with any changes in lifestyle, there are certain risks involved, and I take full responsibility for my health and my choices.
Copy chart
No responses yet for this question.
Waiting for responses
of
10
This form is approaching the response limit. Once surpassed, the question view will no longer be displayed. Learn more
Close
of
1
Loading...
Loading response…
This form is approaching the response limit. Once surpassed, the individual view will no longer be displayed. Learn more
Close
Grades from previous versions of this form are hidden. Learn more
Settings
Release grades
Respondent settings
Global quiz defaults
Default question point value
Point values for every new question
points
Responses
Manage how responses are collected and protected
Collect email addresses
Required by Locked mode
Required to send response copies
Respondents will manually enter their email response
Do not collect
Verified
Responder input
Send responders a copy of their response
Disabled by Locked mode
Requires Collect email addresses
Off
When requested
Always
Requires sign in
File upload
Total size limit for all uploaded files
This limit is smaller than the max size of a single response.
Responses will not be accepted after the limit is reached. Learn more
1 GB
10 GB
100 GB
1 TB
Presentation
Manage how the form and responses are presented
Form presentation
After submission
Confirmation message
We have received your application. You will be contacted by Emma within the next 24 hours. Speak soon!