Eating Disorder Coach Program Application
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Legal Full Name (FIRST, LAST) *
** A payment plan is available where you pay a one-time administration fee of $500.00 and then pay for each module as you progress through the program. Each module costs $516.67, therefore the first payment would be the administrative fee plus the first module for a total of $1,016.67. When you are officially offered a spot to enroll you will need to indicate if you are choosing the payment plan or the full payment up front option.
Date of Birth *
Address (Number and street name) *
City *
State *
Zip Code *
Country *
Email Address *
Phone Number (Home) *
Additional Phone Number (Cell, work, etc.)
Do you have any social media accounts? *
If Yes, please provide the links to your social media profiles / pages below.     E.g. Facebook-    Instagram-     If None - Write "None". *
Gender *
Profession (Include any professional licenses or certificates) *
Current Employer *
Check All of the Following Avenue(s) of Eating Disorder Coaching You Are Interested In: *
Are you currently involved with any eating disorder organizations? This includes volunteers. *
**If yes to the question above, please list the organization(s) you are involved with, for how long and your role(s).
How did you hear about The Carolyn Costin Institute? *
**Please provide specific details about your answer above (i.e. which social media site you saw us on, who specifically referred you, why/what you were searching for online etc.) *
Highest Level of Education Completed: If you did not receive a Bachelor's degree or above, you must answer the following question (request for Bachelor's degree waiver) *
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