Eating Disorder Coach Program Application

THE APPLICATION PROCESS CONSISTS OF TWO STEPS:

STEP 1: The written application (this)

STEP 2: A video submission (instructions will be provided after the written application is submitted)

**Applications are not reviewed until both the written and video submissions are received**

PROGRAM COST $4850

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

Name *

Your answer

Date of Birth *

YYYY

Address (Number and street name) *

Your answer

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

Your answer

Email Address *

Your answer

Phone Number (Home) *

Your answer

Additional Phone Number (Cell, work, etc.)

Your answer

Gender *

Female

Male

Prefer not to say

Other:

Profession (Include any professional licenses or certificates) *

Your answer

Current Employer *

Your answer

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).

Your answer

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:

Your answer

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.)

Your answer

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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