Full Name: *

Preferred Name (if different):

E-Mail Address: *

Phone/WhatsApp (include country code): *

City & Country of Residence: *

Age: *

How did you first discover me or my work? *
YouTubePodcastReferralInstagramSocial Confidence ClubNewsletterOther

Have you watched any of the in-depth client video testimonials or read their stories? *
Yes - I’ve watched at least one full testimonial videoYes - I’ve read or skimmed a few storiesNot yet, but I plan toNo, not yet

What is your current experience with social anxiety? *

How long have you been struggling with this? *

What have you tried in the past to overcome this? *

What worked (if anything)? What didn’t? *

Important Eligibility Note

Before we continue, please take a moment to confirm that this coaching is a safe and appropriate fit for your situation.

I specialize in helping people overcome social anxiety at the root. However, in some cases, there are additional compounding issues that go beyond the scope of this work.

This coaching is not suitable if you:

• "Are currently experiencing severe depression or suicidal thoughts"

• "Have a history of sexual abuse that requires specialized clinical support"

• "Have been diagnosed with Dissociative Identity Disorder (DID), bipolar disorder, OCD, or other complex psychiatric conditions requiring clinical treatment"

If any of this applies to you, please know you still deserve excellent support. I recommend working with a licensed mental health professional who specializes in trauma and clinical care.

I confirm that none of the above apply to me, and I understand that this coaching is not a substitute for clinical mental health treatment.

What You're Applying For:

This is a deep, personalized coaching experience designed to help you fully resolve the root of your social anxiety. It includes:

• Weekly / bi-weekly private 2-hour coaching sessions, for 3-6 months. (Intensity and duration can be adjusted upon discussion)

• Personalized tapping tools, audios, and exercises

• Full access to me between sessions

• Bonus healing sessions (TAT, PSYCH-K)

• Three to six 1-hour support sessions over 2 years

• Private portal access and up to 2 years in the Social Confidence Club

Traditional therapy can bring insight, but even after a year and $20K of sessions, many people still feel anxious.

This process is different. It’s not therapy. It’s a high-level, guided transformation journey with expert support every step of the way.

Clients often go from longstanding, severe social anxiety, to feeling at ease, confident, and connected—without forced exposure exercises.

Private coaching ranges from $15,000 to $30,000 USD, depending on the level of support you choose. Packages vary based on session frequency, bonus support, and long-term access. We’ll explore what’s most appropriate for your goals during the intro chat.

In some cases -when social anxiety is highly specific and not generalized- I occasionally offer a smaller, more focused package.

Satisfaction-in-Session Guarantee

If you decide to invest in private coaching, I want you to feel fully confident in your decision. That’s why I offer this simple guarantee:

If you don’t experience noticeable emotional relief or meaningful insight in our very first session, you can let me know within 24 hours and receive a full refund.

This guarantee applies when you commit to a coaching package. In the past 10 years, not a single person has requested one, but I offer this so you can feel confident moving forward.

I understand private coaching ranges from $15,000 to $30,000 USD, and I am applying as a serious potential client.

What made you decide to reach out now? Was there a moment, event, or realization that made you feel it’s time to address this now? *

Are you financially prepared to invest $15000 - $30,000 in your transformation if this feels like the right fit? *
Yes - I’m fully readyPossibly - I'm serious but need to talkNo - just exploring

When would you ideally want to get started? *
ASAPWithin 30 days1-3 months from nowJust browsing

Are you the sole decision-maker for this kind of investment? *
YesNo, I’d need to consult someone else

If this problem were fully resolved, what would your life look like? *

What’s one thing you most want help with? *

Is there anything else you'd like me to know before we speak? *

Consent Agreement & Waiver

Please read and agree to the following before submitting:

This coaching is powerful, but it’s not therapy. Some techniques are evidence-supported (like EFT), others are emerging or experimental. No guarantees of results are made.

Consent Agreement & Waiver

As part of my session work with the Practitioner, I will engage in various techniques rooted in energy psychology, subconscious transformation, and nervous system regulation.

These may include Emotional Freedom Techniques (EFT), as well as other complementary approaches such as PSYCH-K, TAT, Intention Tapping, MAP, Logosynthesis, and similar tools designed to support emotional well-being and personal growth.

EFT is a mind-body method that combines cognitive reframing with acupressure by tapping on meridian points on the body. It has been supported by over 125 peer-reviewed studies, including meta-analyses and randomized controlled trials, demonstrating its effectiveness for reducing anxiety, emotional distress, and trauma-related symptoms. It is increasingly recognized in integrative psychology and coaching settings.

While EFT is evidence-supported, some of the other approaches used during sessions are considered emerging or experimental and may not yet have extensive scientific validation. All techniques are provided as complementary tools to support self-awareness, nervous system regulation, and emotional healing - not as a substitute for medical, psychological, or psychiatric treatment.

By signing this document, I acknowledge that results vary by individual, and I take full responsibility for any and all outcomes associated with participating in these sessions.

Emotional Risks and Scope of Practice

By participating in the coaching sessions, I understand that it is possible that emotional or physical sensations or additional unresolved memories may surface during the process. These could be experienced as emotionally intense or uncomfortable. I also understand that previously vivid or traumatic memories may fade, which could impact my ability to provide detailed legal testimony regarding a traumatic incident.

I accept full responsibility for my emotional, physical, and psychological well-being before, during, and after all sessions. I understand that I am encouraged to consult with my appropriate healthcare provider regarding any mental or emotional symptoms that arise.

I understand that these coaching sessions are designed to help me access my own innate healing capacity and are not intended to diagnose, treat, or cure any medical or psychological conditions.

Professional Relationship and Limitations

I understand that Sebastiaan van der Schrier is not a licensed medical doctor, psychologist, psychiatrist, or psychotherapist. He does not diagnose conditions, prescribe medications, or offer psychological therapy.

I understand that these sessions are not a replacement for professional mental health care or medical care. If I am currently under the care of a licensed provider or taking prescribed medications, I will not discontinue them without consulting my provider. Even if I experience improvements from the sessions, I understand that it is my responsibility to make informed decisions with the guidance of my healthcare professionals.

Testimonials, Guarantees, and Outcome Expectations

Any stories or testimonials presented before, during, or after my sessions are intended for inspiration only. They do not constitute a guarantee, warranty, or prediction of my personal results. Outcomes vary based on many factors including my commitment, readiness, emotional history, and follow-through.

The practitioner makes no guarantees or assurances of specific outcomes or timeframes. Lack of progress may indicate that other underlying issues are present and may require the involvement of a licensed mental health professional. It is common that more than one modality or approach is needed for complete healing.

Release of Liability and Informed Consent

I acknowledge that I have had the opportunity to ask any questions regarding this agreement and the nature of the services offered.

By signing this agreement, I confirm that:

• I have read and fully understand all parts of this agreement.

• I voluntarily assume all risks associated with participating in coaching sessions.

• I release the practitioner from any and all liability related to my participation, to the fullest extent allowed by law.

• I take full responsibility for my self-care across emotional, physical, mental, and spiritual dimensions.

This agreement is intended to be a complete and unconditional release of liability and assumption of risk, and shall be binding upon me, my heirs, legal representatives, and assigns.

Legal Standing

I confirm that I am an adult under the laws of my country or state of residence and have the legal right to enter into this agreement.

If I am a minor, I understand that this agreement must be co-signed by my parent or legal guardian.

Signature

I confirm that I am over 18, have read and agree to the Consent Agreement & Waiver, and understand this coaching is not a substitute for therapy.

Type your full name to confirm your agreement: *