1:1 Coaching Application: Motherhood Beyond Fear
Please complete the following questions
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Name *
First and last name
Email *
Phone number *
City, State, Country and Time Zone: *
Please describe your current challenges with anxiety and intrusive thoughts in early motherhood: *
Briefly describe the types of intrusive/unwanted/anxious thoughts you are experiencing. Do you notice any similar themes? *
What strategies or tools have you tried to use in order to help yourself feel better? *
On a scale of 1-10, how much are anxiety, fear, and intrusive thoughts interfering with your life? *
I barely notice them - life is pretty unaffected
They are completely taking over my life and I don't recognize myself or my life anymore
Have you ever been hospitalized for mental health reasons? *
Are you currently experiencing thoughts of suicide, self harm, or engaging in self harm? *
Are you currently working with a mental health professional? Therapist, psychologist, psychiatrist, etc. *
On a scale of 1-10, how committed are you to making changes in your life in order to overcome your current struggles with intrusive thoughts and anxiety? *
not committed at all, I don't want to make any changes
Completely committed, I will do anything to change what's happening
What would success look like to you after having worked together?  *
What's the cost of staying where you are vs. getting uncomfortable and making changes? *
How did you hear about me? *
After reviewing your application, I will reach out to you at the phone number you provided to find a time to have a brief phone call. Please expect for me to reach out within 24 hours of receiving your application. I'm looking forward to speaking with you! *
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