Eating Disorder Coach Program Application

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Legal Full Name (FIRST, LAST) *

PROGRAM COST $6200

** 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 *

YYYY

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? *

Yes, I have social media accounts

No, I do not have any social media accounts

Required

If Yes, please provide the links to your social media profiles / pages below. E.g. Facebook-https://www.facebook.com/carolyn.costin/ Instagram- https://www.instagram.com/ccicoaching/ If None - Write "None". *

Gender *

Female

Male

Prefer not to say

Other:

Profession (Include any professional licenses or certificates) *

Current Employer *

Check All of the Following Avenue(s) of Eating Disorder Coaching You Are Interested In: *

I want to open my own eating disorder coaching service/business

I want to enhance my current coaching business to expand into eating disorders

I am a clinician and want to obtain additional training to better serve my clients

I am already in a service career (yoga teacher, personal trainer, educator, etc.) and want to best help my eating disorder clients

I currently work for a coaching business and want/need to get certified

I want to work for an existing coaching business after I am certified

Other:

Required

Are you currently involved with any eating disorder organizations? This includes volunteers. *

Yes

**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? *

Social Media (Facebook, Twitter, etc.)

Carolyn’s website

Carolyn’s lecture/workshop

Received a flyer/mailing

Online search

Friend/referral

Coaching organization

Other:

Required

**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) *

**High School Diploma or Equivalent (waiver required)

**Some College (waiver required)

**Associate’s Degree/Two-Year Technical Degree/Vocational School (waiver required)

Bachelor’s Degree

Graduate or Professional Degree

Other:

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