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RYD Application

Thank you so much for you interest in the reClaim Your Desire Program. It's important to us that you're a good fit for our program so please complete all the questions. You will be notified about your status within 48 hours. With care, Rachel & Xanet

1. Name *This question is required.

2. Phone Number *This question is required.

3. Email *This question is required. This question requires a valid email address.

4. Tell us briefly why you are interested in attending this program: *This question is required.

5. Is there anything going on in your personal life that will prevent you from being able to give your full time and attention to this program? *This question is required.

Please explain briefly what is going on in your personal life that might prevent you from being able to give your full time and attention to the program: *This question is required.

6. Are you able to regularly attend the bi-monthly calls on 2nd & 4th Wednesdays @ 3:30p-5:00p PT / 6:30p-8:00p ET from MARCH 1st - JANUARY 8th? (exceptions: November meetings will occur on 11/13 & 11/21; December meetings will occur on 12/11 & 12/19; Celebration call: 1/8/25) *This question is required.

7. Are you able to make 10 monthly payments of $325? *This question is required.

8. Are you currently... *This question is required.

Please enter an 'other' value for this selection.

9. Are you currently sexually active either with a partner/partners or with yourself (masturbate)? (Check all that apply) *This question is required.

Yes, I am sexually active with a partner
Yes, I am sexually active with myself
No, I am not sexually active with a partner
No, I am not sexually active with myself

10. Are you currently working individually with a therapist or coach who is specifically trained in trauma? *This question is required.

11. In the past five years, have you worked individually with a therapist or coach who is specifically trained in trauma? *This question is required.

12. Have you experienced any of the following? *This question is required.

Sexual Abuse
Physical Abuse
Emotional Abuse
Verbal Abuse
Rape/Assault
Other - Write In (Required) Please enter an 'other' value for this selection. * This question is required.
None of the above
Prefer not to answer