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Apply SBC

Tell us a little about your situation. 

It should take between 10-15 minutes to answer these 10 questions. You'll hear back from us within one bussiness day. 

 

 

Start

Question 1 of 15

Name, age, phone number, email address?

Question 2 of 15

Which program are you applying for? 

A

4 weeks Recovery Coaching With Amber

B

8 weeks Recovery Coaching With Amber

C

12 weeks Recovery Coaching With Amber

Question 3 of 15

What time zone do you live in?

Question 4 of 15

Tell me a little about the situation you're wanting help with? 

Question 5 of 15

What have you tried in the past?  (counseling, treatment, 12-step meetings, other..) 

Question 6 of 15

Why is this the right time to address this problem? 

Question 7 of 15

What outcome are you hoping for?

Question 8 of 15

Why do you think Amber is the right person to help you with this? 

Question 9 of 15

What's the biggest factor motivating you to make a change? 

Question 10 of 15

Are you wanting to start this month or next? 

Question 11 of 15

Amber typically sees clients on Tuesdays and Wednesdays, will that work for you?

(Select all that apply)
A

Yes

B

No

Question 12 of 15

Anything else we should know? 

Question 13 of 15

Have you had a chance to look over the FAQ's for this program? 

A

Yes

B

No, but I will

C

No, I have all the information I need.

Question 14 of 15

Do you have any questions about the program?

Question 15 of 15

Quick note about our appointment policy:  Because we have a very limited number of spots in this program, we are unable to reschedule missed and late cancellation appointments.  

A

Acknowledged

Confirm and Submit