Eating Disorder Coach Program Application
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Name *
** 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 any of your social media links, for example, (i) Facebook, (ii) Instagram, (iii) Twitter, (iv) Tiktok, (v) LinkedIn, (vi) YouTube channel. If None - Write "None". *
Gender *
Profession (Include any professional licenses or certificates) *
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