First Name
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Last Name
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Email
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Phone
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Are you diagnosed bipolar?
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Yes
No
If so I or II?
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Select
Bipolar I
Bipolar II
Prefer Not To Say
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Are you on medications?
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Yes
No
Are you opposed to meds or haven’t found the right fit?
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Opposed to meds
Haven’t found the right fit
Are you currently in a manic state
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Yes
No
Are you in a depressed state (constant or ups and downs)
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Yes
No
Are you looking for help with your disorder?
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Yes
No
Are you willing to invest in your own mental health if I’m the coach and fit you’re looking for?
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Yes
No
Are you willing to take advice from someone who has walked in your shoes
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Yes
No
Are you ready live a glass half full kind of life?
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Yes
No