DRIVEEASE PROGRAM - M Club Health & Wellness Centre

Name: *
Email: *
Cell Phone: *
Time Zone:

Looking forward to connect with you.  Please take NO MORE THAN 5 MINUTES to answer a few intake questions. 

How high is your driving anxiety out of 1000?

{"type":"radio","name":"__generic","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the above options.","options":"1000 (extremely high)\n750 \n500\n250\n0 (No Anxiety)"}

How long have you had driving anxiety?

{"type":"textarea","name":"preSessionExcited","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item, even if it's just typing in \"Nada\". :)","height":80,"placeholder":"Could this fear have been passed down genealogically? "}

What is ideal realistic outcome you are looking for? (Passing road test, driving freely on highway etc.)

{"type":"textarea","name":"preSessionStuck","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Really? If so, please just proudly declare that you are ON FIRE. :)","height":80,"placeholder":"How eagerly do you want your FREEDOM?"}

How high sincerely is your motivation to overcome your driving your driving anxiety?

{"type":"radio","name":"__generic2","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the above options.","options":"100\n75\n50"}

What wouldn't happen if you don't learn to drive with confidence? How will your lifestyle be effected? (emotionally, financially physically and socially) 

{"type":"textarea","name":"__generic3","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"Imagine all the opportunites you will miss or have missed out on?"}

How much have you spent and plan to spend in driving lessons in trying to eliminate or reduce the driving anxiety? 

{"type":"text","name":"__generic4","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}

When would you sincerely like to get rid of driving anxiety  completely? 
{"type":"checkbox","name":"__generic5","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"A Few Years\nA Few Months\nA Few Weeks \nNow\nYesterday"}

How would it make you feel if you had absolutely no fear behind the wheel? (Please describe in detail the benefits of getting over the fear)
{"type":"textarea","name":"__generic6","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

We sincerely thank you for taking the time to fill out the form. You have taken the first step towards your driving freedom. We will review your questionnaire and connect with you shortly. “What you seek is seeking you.” Rumi