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Intake form
Help us serve you better
Name
*
Email address
*
What is your primary reason for seeking help with your fear of flying?
Please select at least one option.
Panic attacks during flights
Fear of heights
Previous traumatic experiences
General anxiety about flying
Fear of losing control
Have you previously attended any workshops or therapy sessions related to fear of flying?
Select
Yes
No
What type of support are you most interested in?
Please select at least one option.
Flight simulation experience
Therapeutic support
Guidance from a professional pilot
Group seminars
Individual sessions
How would you describe your current level of fear when it comes to flying?
Select
Mild
Moderate
Severe
What is your preferred method of communication?
Select
Email
Phone
In-person
Video Call
Do you have any specific goals you hope to achieve through our program?
Are there any specific dates or time frames when you would like to participate in the program?
Which service or services are you interested in?
Please select at least one option.
Flight simulator experience
Expert pilot guidance
Therapeutic support
Seminar purchase
Initial consultation for $150
Follow-up consultation for $100
Additional questions or comments
Submit
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