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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