Eating Disorder Coach Program Application

Name *

PROGRAM COST $4850

**A payment plan is available. More details are provided in the student contract and on the "FAQ" on the website.

Date of Birth *

YYYY

Address (Number and street name) *

Address (City, State, Zip Code and Country) *

Email Address *

Phone Number (Home) *

Additional Phone Number (Cell, work, etc.)

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).

Have you been trained as a Carolyn Costin Eating Disorder Mentor? *

Yes

**If yes to the question above, please answer ALL of the following: (1) Name of organization (2) Date of mentor diploma (3) Dates served as a mentor (4) Please briefly describe your experience:

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

**If you can provide more specific details about your answer above, we would love to know (i.e. which social media site you saw us on, who specifically referred you, 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

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