HeartSpace Academy Application
Please complete the below application to be considered for HeartSpace Academy.
Email address *
Name (first, last): *
Your answer
Best phone number to reach you: *
Your answer
City, State: *
Your answer
Age: *
Your answer
How did you find me? *
Your answer
Highest level of education? *
Your answer
Occupation: *
Your answer
Which option is most appealing to you - HeartSpace Academy or HeartSpace Academy Accelerator *
Why HeartSpace Academy now? *
Your answer
Describe your current relationship with food & your body. *
Your answer
What do you want your relationship with food & your body to look like in 3 months from now? 6 months from now? *
Your answer
On a scale of 1 to 10, how important is making peace with food & healing body image issues to you right now? *
Not at all important.
The most important thing to me.
What are you currently doing to support your relationship with food & your body? *
Your answer
What's your biggest hurdle when it comes to food & your body image right now? *
Your answer
Are you ready to make the commitment to working through these hurdles - time-wise, financially, and emotionally? Why or why not? *
Your answer
Would you consider yourself an open-minded person? Why or why not? *
Your answer
Have you worked with therapists, dietitians, coaches, or other healing modalities before? Or, are you currently? If yes, please share about your experience. *
Your answer
Is there anything else you'd like me to know?
Your answer
Thank you!
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