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RBF RECOVERY Application
I am celebrating you for choosing yourself and committing to your healing journey after a toxic relationship. The next step is to complete the application to make sure the program is a good fit for you! Kel will send you an email to coordinate a time to connect to discuss the next steps!
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* Indicates required question
Email
*
Your email
Full Name
*
Your answer
Instagram Handle:
Your answer
Have you ever experienced a toxic relationship?
*
Yes
No
Currently in one
How long have you been out of the relationship?
*
0-3 Months
3-6 Months
6-12 Months
12+ Months
I'm still stuck in one
On a scale of 1 to 10, how much is the aftermath of the relationship affecting your life?
*
Life feels good
1
2
3
4
5
6
7
8
9
10
Life is hard af
Are you still in contact with your ex?
*
Yes
No contact
No response
I'm currently struggling with (check all that apply):
*
Feelings like doubt, guilt, blame, confusion, and shame
Low self-esteem
Lack of confidence
Not feeling like myself
Not knowing who I am
Not trusting myself
Ruminating and obsessive thoughts about an ex
Repeating the pattern of toxic relationships
Fear and uncertainty about the future
Other:
Required
I really want to (check all that apply):
*
Feel confident
Trust myself
Not question or doubt myself
Learn to put myself first and be a priority in my life
End people pleasing and codependency
Remove shame and guilt
Attract healthy partners
Learn not to fear “being alone”
Be happy being single
Improve self-esteem
Learn healthy boundaries
Other:
Required
What would you like support with? What are you hoping to get from this program?
Your answer
Is there anything else that you would like me to know?
Your answer
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