Freedom From Food Addiction Application
First Name
Your answer
Last Name
Your answer
Date of Birth
Your answer
E-mail Address
Your answer
Phone Number
Your answer
Best time of day to call?
Time Zone
Your answer
How would you describe the type of food addiction you're dealing with? (e.g. Bulimia, Anorexia, Binge Eating Disorder, etc.)
Your answer
Please rate the severity of your food addiction on a scale of 1-10.
Not bad at all
Extremely severe
Are you currently under a physician's care?
How many hours per week are you able to commit to your recovery?
Your answer
On a scale of 1-10 how badly do you want to free yourself from your food addiction?
It's not urgent
I'll do anything
How did you find out about this course?
Your answer
Do you have any questions?
Your answer
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