Alcohol Freedom

Application

Momentum Application

Thank you for taking this step. Before we dive in, I want you to know: whatever you share here stays completely between us. There’s no judgement in this space... only curiosity, and a genuine desire to understand where you’re at.

Take your time with these. Some of the questions are simple, some might take a little more reflection. There are no wrong answers.

Which programme are you applying for?

Getting to Know You

Your Journey So Far

A Little More About You

Please read our privacy statement here, and tick below to confirm you’ve read them.

Your Details

Optional.

Optional — city and country is plenty.

Your Health and Safety

Coaching with us is an educational and motivational service to help you reduce or stop drinking alcohol. It is not medical care, psychology, counselling or treatment, and it doesn’t replace advice from your doctor or other health professionals.

We ask the questions below so we can understand your situation, coach you safely, and know who to contact if a safety concern ever arises. You don’t have to answer every question, but the more we know, the better we can support you. Everything here stays confidential, in line with our Privacy Policy and Coaching Services Agreement.

Tick any that apply, and add detail if you can.

Optional but encouraged — for example, depression, anxiety, bipolar, PTSD, an eating disorder, or a physical condition.

You don't need to list specifics if you'd rather not — just let us know if this applies.

Alcohol and Withdrawal Safety

Reducing or stopping alcohol can, for some people, cause withdrawal symptoms that are serious, or even life-threatening. This section simply helps us keep you safe.

Tick any that apply.

Only share what you're comfortable with.

If you’ve experienced serious withdrawal symptoms before, or you drink heavily or daily, we strongly recommend speaking with your doctor before making significant changes, so any withdrawal can be managed safely. We’re always happy to talk this through with you.

Your Wellbeing, Right Now

People going through this kind of change sometimes move through difficult periods. We ask this gently, and only so we can support you well and point you toward the right help if you need it.

If you’ve ticked “Sometimes” or “Yes,” please know support is available and you are not alone. You can call Lifeline on 13 11 14, or 000 in an emergency, at any time — and we’d encourage you to speak with your doctor too.

Once your application is sent, you’ll be able to book your discovery call with Rina straight away.