Are You Ready To Kickstart Your Recovery?
Email address *
Name *
In a few words, how have you been affected by Narcissistic Abuse? *
Are you currently in No Contact with the Narcissist? *
If you ticked "Modified Contact", "We are in touch regularly" or "Other", please explain your situation in a few words
What has been the impact of Narcissistic Abuse on all different aspects of your life? (work, relationships, quality of life etc.) *
Which of these symptoms are you experiencing? *
If you ticked "other", please specify:
What outcome would you like to achieve as a result of attending Roni's award-winning Narcissistic Abuse Recovery Coaching Kickstart Programme? Please be really specific! *
What expectations do you have of this programme? *
How willing are you to invest in yourself and your own well-being? *
Not at all really
Yes, I'm my own best investment
I have the time to invest in myself *
I have the money to invest in myself *
I can make and keep appointments with myself to work on this *
I am fully willing to do the work required to get me where I want to go *
I am willing to stop or change the self-defeating behaviours that limit my success *
I am willing to try new things even if I am not 100% convinced they will work *
I have the patience to take consistent action towards my goals, regardless of how immediate the results are *
How important is it for you to heal from this? *
I don't really care
My healing is my no.1 priority!
How committed are you to making this happen? *
Absolutely, I'm 100% all in!
What tools, approaches and methodologies have you explored to recover from Narcissistic Abuse? *
If you've explored therapy and other intervention methods before, what has been your biggest frustration?
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) *
If you ticked "yes or Maybe", which condition(s) are you referring to?
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) *
Have you seen a psychiatrist in the last 12 months? *
• I am fully aware that Narcissistic Abuse Recovery Coaching does not prevent, cure or treat any mental disorder or medical disease. • I acknowledge that results are not guaranteed and are dependent on my commitment. • I know that when entering the NARC Kickstart Program, accountability and responsibility for my results lie with myself. As such you agree that the Coach is not and will not be held liable for any action or inaction, or for any direct or indirect results of any services provided by the Coach. • I understand that the Coach is a certified Personal Development Coach, Master Practitioner and Trainer of Neuro-Linguistic Programming, Clinical Hypnotherapist and Havening Techniques Practitioner. I agree to allow her to guide me through any processes relevant for me to achieve the goals you have set. *
Is there anything else you would like to add to support your application?
Never submit passwords through Google Forms.
This form was created inside of White Lotus Coaching & Consulting Ltd.. Report Abuse